Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CO' RUCTION OR PUMP PERMIT Permit No. � a „J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is wade in compliance with San Joaquin <br /> County .Ordinance .No-. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name V <br /> _ Phone <br /> Address ere:) e City �'Y1f22 <br /> I <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check) : NEW WELL /�.�EEPEN RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / J PUMP REPLACEMENT /_7 �v <br /> Other /% — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED- USE TYPE OF WELL <br /> CONSTRUCTION SPECIFICATIONS <br /> Industrial l.-Cable Tool Dia, of Well Excavation y <br /> 1.�omestie/private Drilled Dia, of Well Casing 1 <br /> Domestic/public Driven Gauge of Casing m <br /> V Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout yqy <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done J <br />�PUMP_REPA1R: ,. ' _ J <br /> / /�•=-S�t�-te*Work=-Done .T - _ <br />,ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure 4 <br /> 'I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating we`ll construction. Within FIFTEEN DAYS d <br /> 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 well- and notify them before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. , <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE ✓SID -- <br /> FOR DEPARTMENT USEAONLY �! <br /> PHASE I { <br /> APPLICATION ACCEPTED BY t ... DATE <br /> ADDITIONAL COMMENTS: { <br /> PHASE I INSPECTION » PHASE III FINAL INSPECTION I <br /> INSPECTION BY DATE -�. INSPECTION BY DATE _ _ f <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND F.INAL: INSPECTION. <br /> E H 1426 7/72 1M i <br />