Laserfiche WebLink
i` <br /> I <br /> �o <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF. OFFICE USE: 1601 E. Hazelton Ave, , Stockton, Calif. <br /> Telephone: (201) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No: ,7�_L3_L <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Z/ <br /> M ' <br /> iM (Complete In Triplicate) i <br /> Application is hereby spade to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. ' This application is made in compliance with San Joaquin J <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. F <br /> .TOB ADDRESS/LOCATION CENSUS TRACT - <br /> Owner's Name Phone <br /> Address /. J`� City _ r <br /> S - - — License # Phone, <br /> rs Name ' <br /> Contractoc -- <br /> TYPE OF -WORK (Check) : NEW WELL '/ DEEPEN '/ / RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION / PUMP REPAIR '/ / PUMP REPLACEMENT /? <br /> _ r <br /> Others / / <br /> DISTANCE TO NEAREST: SEPTIC'--TANK 3U,' SEWER LINES PIT PRIVY <br /> SEWAGE' DISPOSAL..FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS .^W <br /> Industrial M Cable Tool Dia. of Well Excavation <br /> Domestic/private _ Drilled Dia. of Well Casing <br /> Domestic/public i Driven Gauge of Casing <br /> 4 Irrigation G Gravel Pack. Depth of Grout Seal � <br /> Other .i Rotary Type of Grout <br /> ji� Other Other Information �4 <br /> PUMP INSTALLATION: Contractor <br /> Type 'of Pump f H.P. <br /> i <br /> PUMP REPLACEMENT: / / 'State Work'Done <br /> PUMP UPAIR: State Work Done <br /> I <br /> DFgTRUCTION OF WELL: Well ;Diameter `r _ Approximate Depth r <br /> - Describe Material and Procedure <br /> iI <br /> I hereby agree to comply wi '.h all laws and regulations of the San Joaquin Local Health District <br /> and the State of Californiaipertaining to or regulating well 'construction. Within FIFTEEN DAYS <br /> I after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS .REPORT of "the �wel.1 and notify them before putting the well in use.. The above <br /> information is true to the best of my knowledge and belief. <br /> "ii <br /> r <br /> SIGNED7)��_25j. TITLE <br /> ;K (DRAW PLOT PLAN ON REVERSE SIDE) <br /> f i FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE _/•-- 1,/-7y <br /> ADDITIONAL COMAfENTS: IM <br /> PHASE II GROUT:IbINSPECTION PHASE III/F NAL INSPECTION <br /># INSPECT;ON BY JDATE INSPECTION By__ f DATE/ <br /> CALL.FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> 4 E H 1426 I 5/731M -. <br />