Laserfiche WebLink
. <br /> SAN JOAQUiN LCJCAI, HEALTH DISTRICT <br /> Stockton, Calif. <br /> FOF.:OF1xCE USE: 1601 E. Hazelton Ave. ,, <br /> Telephone: (209) 466-6783 <br /> APPLICATION FOR WELL CONST RUCTION. OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES I YEAR FROM DATE '•ISSUED Date Issped y� -7 <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 Rut a Regulations of the San Joaquin Local Health nisrict._._ <br /> k-_C• <br /> / �� oac.G✓1 �" CENSUS TRACT' <br /> JOB ADDRESS/LOCATION 'Z/ ; <br /> Phone ��r <br /> Owner's Name <br /> Address <br /> t� Phone- &2--V-License ����f3`53� Phone <br /> Contractor's Name <br /> i <br /> TYPE OF WORK (Check) : NEW ALL DEEPEN '/ / RECONDITION / / DESTRUCTION -/_7 <br /> PUMP INSTLATION ) / PUMP REPAIR / / PUMP REPLACEMENT IT <br /> AL <br /> Other <br />' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRI - <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> : <br />' INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial a le Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> _ Driven Gauge of Casing <br /> Domestic/public s <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other y <br /> Rotar Type of Grout <br /> - - <br /> -- -- Other Other Information ` <br /> PUMP INSTALLATION: Contractor <br /> H.P <br /> Type of Pump <br /> PUMP REPLACEMENT. / / State Work Done <br /> PUMF 'tEPAIR: / / <br /> State Work Dane <br /> Approximate Depth <br /> ,D'F•sTRUCTION OF WELL: Well Diameter _ <br /> Describe Material and Procedure <br /> hereby agree to comply with all- laws and regulations of the San Joaquin Local in FIFTEEN DAYS <br /> � h y � <br /> and the State of California pertaining to or regulating well •constructian. Within <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District <br /> WELL DRILLERS REPO of .the well and notify them before putting the well in use. The above <br /> informat' n 's tr e t the best of my knowledge and belief. <br /> SIGNEDTITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED, BY <br /> ADDITIONAL COMMENTS: PHASE III/ NAL SPECTiO <br /> PHASE II GROUT INSPECTION NSPECTION BY TE 4 <br /> INSPECTION BY DATE ' <br /> r = • <br /> i. <br /> CALL FOR A GROUT .INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. .:�731M ..} <br />