Laserfiche WebLink
' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <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 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 Rules and Regulations f th San Joaquin Local Health District.' <br /> JOB ADDRESS/LOCATI '7(; CENSUS TRACT <br /> Owner's Name �G� Phone f <br /> �s <br /> AddressL Cit <br /> d� . y �,�'/j6=•2:-Gc.-ua� <br /> Contractor's Name � License # Phone 3- <br /> ^ Gr <br /> TYPE OF WORK (Check): NEW WELL J J DEEPEN /-7 RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION 0 PUMP REPAIR /—/ PUMP REPLACEMENT /7 <br /> Other / / <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 A <br /> Industrial Cable Tool Dia. of Well Excavation `a <br /> Domestic/private Drilled Dia, of Well Casing ri <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 /> s <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump / H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ,DESTRUCTION 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 thew in use. The above <br /> information is true to the Mst of my knowledge and belief. <br /> SIGNED ,.9 TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIL <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I � � <br /> APPLICATION ACCEPTED BY � DATE A-3r2 -- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS19 III;IF-I-NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BYY� _ . DATE -2-t1.. .3 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />