Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601. E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT '---Permit No. <br /> 1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issueds ; <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 made in compliance with San Joaquin <br /> County Ordinance. No. '1862 and the Rules and Regulations of t e San Joaquin Local Health District. t <br /> JOB ADDRESS/LOCATION` _- CENSUS TRACT <br /> Owner's Name Phone <br /> 1 <br /> Address : City , <br /> Contractor's Name <br /> L cense #5 - 4�1`!. Phone �1� <br /> 4 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION /_7 DESTRUCTION /_ <br /> PUMP INSTALLATION / / - P R$PAIR / ( PUMP REPLACEMENT /- <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER JL <br /> i <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS O <br /> Industrial Cable Tool Dia, of Well Excavation �> <br /> Domestic/private Drilled Dia, of Well Casing f <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump I H.P. <br /> ,--..— <br /> PUMP REPLACEMENT: / / State Work Done. <br />=PUMP REPAIR: / / State Work Done _. .... _ - <br />,DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe material and Procedure <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 well construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a 4 <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is true stogy a best of my knowledge and belief. , <br /> SIGNED � � .. TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTEDB U © DATE <br /> ADDITIONAL COMMENTS: _ n_15 <br /> PHASE II GROUT INSP2CTION PHASE_ _ /FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION- PRIOR TO GROUTING .AND FINAL INSPECTION. <br /> E H 1426 7/72, 1M <br />