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. �3 232,E <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete <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 Joaqui <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION tow <br /> CENSUS .TRACT <br /> k <br /> Owner's Name ' <br /> !S2 4 Phone 3 ^ yO�l <br /> i Address _ ''(p (0� f - <br /> ` City <br /> Contractor's Name , License Phone3L <br /> 6 <br /> TYPE OF WORK (Check): NEW WELL DEEPEN / / -RECONDITION /? DESTRUCTION /_7 <br /> AL <br /> PUMP INSTLATION PUMP REPAIR PUMP REPLACEMENT /_7 <br /> Other / / — — <br /> DISTANCE TO NEAREST: SEPfiIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT - OTHER <br /> ! INTENDED USE TYPE OF WELL F CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation � <br /> Domestic/private Drilled Dia: of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation .. .Q.�` Gravel•`Pack,­ Depth of Grout Seal <br /> Rotary � <br /> Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor .� <br /> Type of Pump , . <br /> H.P. <br /> PUMP REPLACEMENT: 'Y. <br /> State Work Done - <br /> `PUM REPAIR ' ' Stale Work Done <br /> ESTRUCTION OF WELL: Wel-1 Diameter <br /> Describe Material and Procedure Approximate Depth <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 ori 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 jt�� <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I i <br /> APPLICATION ACCEPTED BY _ <br /> ADDITIONAL COMMENL <br /> DATEs T �-- <br /> PHASE G 0 N ON PHA- I I/FINAL� INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE i <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION, <br /> E H 1426 . <br /> 7/72 IM <br />