Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Oc. OIF1L'1. 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 Issued3 <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. 1$62 anlhe�Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> ✓� ChQr� ENSUS TRACT <br /> Owner's Name �`►6"c .� . <br /> Phone <br /> AddressCity <br /> c e <br /> Contractor's Name <br /> . � ''4 � '" License � XJ**Phone , <br /> TYPE OF WORK (Check) : NEW WELL j / DEEPEN %/ RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> 1 e. <br /> DISTANCE TO NEAREST: SEPTIC TANKS SEWER LINES PIT�PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing Gl1 <br /> Domestic/public Driven Gauge of Casing L(J <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout ° <br /> Other Other Information <br /> P `~ <br /> UMP INSTALLATION: Contractor ,....... <br /> Type of Pump H.P. <br /> r <br /> PUMP REPLACEMENT: --U State Work Done <br /> PUMP UPAIR: /_/ State Work Done <br /> DFRTRUCTION OF WELL: Well Diameter ! �`" " REtri <br /> Describe Material and Procedure Approximate Depth <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 o edgend belief. <br /> SIGNERS <br /> TITLE f <br /> DRAW PLOT PLAN ON VERSE SIDE) j <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY t,6e7 '. <br /> ADDITIONAL C0.2iiENTS: DATE <br /> PEASE II G111111 UT INSPECTION PHASE III/FINAL INSPEC'TIO _ <br /> INSPECTION BY DATE INSPECTION BY <br /> DATE <br /> CALL FOR A GROU�INSP ECTION PRIOR TO GROUTING AND FINAL INSPECT N. <br /> E H 1426 <br /> 5/731M <br />