Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> "Jy, 01"I CL, USlE: ` 1601 E. Hazelton Ave. , Stockton, Calif. <br /> -� Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ZZ_Vld <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued t�-3-orf <br /> (Complete In Triplicate) <br /> Application is hereby jade to the San Joaquin Local Health District for a permit to const€u t <br /> and/or install the work herein described. , This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Raes and Regu 'lo d the San Joaquin Local. Ile;:1 t.h District. <br /> JOB ADDRESS/LOCAT 1 1?1 r �L'rr�rtS � � CENSUS TRACT <br /> Owner's Name- �F �� �'�'► C �s-� r Phone ; / 6 <br /> Address o cf . J 1►/tvt,s� City - <br /> Contractor's Name zL �t _�(� e i�r License , Phonet 7 <br /> TYPE OF WORK (Check) : NEW WELL jA DEEPEN / i RECONDITION / / DESTRUCTION /-7 <br /> PUMT INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /-T0%her L/ <br /> DISTANCE TO NEAREST: SEPTIC T;°,,v1: _ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSA FIELD CESSPOOL/SEEPAGE PIT OTHERI <br /> INTENDED USE TY E OF WELL CONSTRUCTION SPECIFICATIONSC1`t <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 PumpH.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP UPAIR: / / State Work Done O <br /> DFCTRUCTION 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 /> iter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> ttiELL D' S REPORT of the well and notify them before putting the well in use. The above <br /> inLorma 'on is ue to the best of my knowledge and belief. <br /> SIGNEDTITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PdASE I _ <br /> APPLICATION ACCT11.PTSD BY DATE <br /> ADDITIONAL COMMNIENTS: <br /> PHASE II GROUT INSPEC'T'ION PHASE III/FINAL INSPECTION <br /> INSPECTION BY 1G — DATE .,r INSPECTION BY DATE zj <br /> CALL EOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E F, 1426 5/731M <br />