Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOI.-*OFFICE USE: 1601. E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209.) '466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 73- <br /> THIS PERMIT EXPIRES I 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 Joaquinl <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 <br /> 4i2s Phone FJ ,� 7 <br /> Address of City , <br /> � <br /> Contractor's Dame , i2 � ,ds.1 _.�.� ---_- _--- _ License # !Ld jtZ Phone-- Z , i <br /> i <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN '/ / RECONDITION /_/ DESTRUCTION <br /> ALf� <br /> PUMP INSTALLATION / / �PUMP REPAIR '/—/—PUMP PUMP REPLACEMENT /4- I <br /> Other ! 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> , SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER Rjn., <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation i <br /> Domestic/private Drilled Dia. of Well Casing <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 H.P. <br /> PUMP REPLACEMENT: / / State Work Done a <br /> PUMP 'tEPAIR: !—/ State Work Done <br /> ,DFCZTRUCTION 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 my knowledge and belief. <br /> SIGNED TITLE <br /> (D PLOT PLAN ON REVERSE SIDE) <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED .BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II aOVT 7%iSP=ION PHAS ! . NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION <br /> • CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. ^ 21 <br />