Laserfiche WebLink
I <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOL:OFFILE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ' <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <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 made in compliance with San Joaquin . <br /> Count Ordinance N l8odgand the Rules and Regulations of the San Joaquin Local He�ilth District. <br /> I <br /> .TOB ADDRESS/LOCitION - Qr � Imo' - - '� S CENSUS TRACT ' <br /> Owner's Name 13 o Co cL Phone 9 J <br /> Address Aa 1 �1 �l S City �] 1 <br /> Contractor's Name License3 `Phar�e� /3 <br /> 7 <br /> TYPE OF WORK (Check) : NEW WELL /✓J� DEEPEN '/_/ RECONDITION /—/ DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_ <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TA11K SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial "bol Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Dom stic/public Driven Gauge of' Casing <br /> rrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP `ZEPAIR: / / State Work Done <br /> .DFgTRUCTION 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 <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 m knowledge and belief. ; <br /> SIGNED aad 9C, TITLEC Ul__22� <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br />' FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> s APPLICATION ACCEPTED BY ��� G�T�'��. DATE /Q <br /> ADDITIONAL COIMENTS: <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE B.J <br /> 6 I <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. ��,, <br />