Laserfiche WebLink
_ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> T711 rOF'F10E USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> t� Telephone: (209)466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7S- jo <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 con trust <br /> and/or install the work herein described. ' This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> z <br /> i <br /> JOB ADDRESS/LOCATION CENSUS TRACT t <br /> i <br /> Owner's Name <br /> Phone <br /> f <br /> Address � . <br /> City <br /> Contractor's Name // �G-l�-G� License Phone <br /> s�- <br /> TYPE OF WORK (Check) : NEW WELL /-7 DEEPEN / / RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION // / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other /-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS \(1 <br /> Industrial Cable Tool Dia. of Well Excavation C. <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 0 <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump -- H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP 'tEPAIR: / / State Work Done <br /> DF�TRUCTION 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 /> _ DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED �,. �.. ., .� , ,Q DATE v <br /> ADDITIONAL CO',QENTS: <br /> PHASE I . ROUT INSPECTION PHASE III/FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 5 , 731m <br />