Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE 1601 E. Hazelton Ave. , Stockton, Calif, <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �4 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued !/ /6 ,-ZL <br /> (Complete In Triplicate) <br /> Application is .hereby made to the San Joaquin Local Health District for a permit toconstruct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No, 18 2 nd t Rules and -Regulations of the San Joaquin Local Health District, <br /> l�ossla of7-r so, z <br />, . JOB ADDRESS MOCATION CENSUS TRACT <br /> Owner's Name /Zo-�- 7- <br /> Phoneur• <br /> Address City <br /> i Contractor's Name License #. hone <br /> �. ,..4_.,. V - �— <br />{ TYPE OF WORK {Check) : NEW WELL /7� DEEPEN /7RECONDITION QESTRUCTION /7PUMP INSTALLATION / / PUMP REPAIR / / REPLACEMENT /7 <br /> Other /-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWE LI S PIT PRIVY A <br /> SEWAGE DISPO FIELD CE S OOL/SEEPAGE PIT OTHER _ <br /> fh <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> -- Domestic/public. - Driven j Gauge of Casing <br /> Irrigation Gravel Pack, _, Depth of Grout Seal <br /> Other Rotary ,Type of Grout A <br /> , . <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done �. <br /> 1PUMP REPAIR: / / State Work Done - <br /> .ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> ^^ Describe Material and Procedure <br /> M - <br /> CI 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- ORT of the Vely and notify them-before putting the well in use The above <br /> information i t ueto he b of m knowledge `and belief. <br /> . SIGNED TITLE <br /> i (DRAW T PLAN ON REVERSE SID <br /> 0 DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY _ / � ,��// DATE "7 - <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> ; INSPECTION BY DATE INSPECTION BY DATE 42��•]�! <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 < . 7/72 1M <br />