Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICESE: 1601 H. Hazelton Ave. , Stockton, Calif. <br /> 1/1 JA JAI -I Telephone: (209) 466-6781 <br /> s ! APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> � <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 of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION `i4 '" <br /> A CENSUS TRACT <br /> OwnW s 'N _T <br /> ame <br /> 6�.�" �®.S _ Phone <br /> Address &e-" liow,& City414 41akr/L <br /> L <br /> Contractor's Name . License # ® y,�Phone <br /> ai 7 <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN / / RECONDITION /-7 DESTRUCTION /7 <br /> PUMP INSTALLATION /L4/ PUMP REPAIR PUMP REPLACEMENT /7 <br /> Other / / — � <br /> i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> i <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> flndustrial Cable Tool Dia. of Well Excavation <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 <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> EType of Pump r.21� E.�Fa H.P. <br /> V �I <br /> V PUMP / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ,PESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> j 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 my knowledge and belief. <br /> j <br /> SIGNE ! ,41A , TITLE <br /> C! W PLOT PLAN ON VERSE SIDE <br /> i <br /> FOR DEPART USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY r. DATE Z I <br /> ADDITIONAL COMMENTS: <br /> PHAS§,Ij GROUT INSPECTION PHASE FINAL INSPECTION <br /> -- <br /> INSBY <br /> .. <br /> TION BY DATE INSPECTION DATE 3 " <br /> i <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSP 0ION. <br /> E H'A426 7/72 1M <br /> e <br />