Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> —FO F. 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 �--7 <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 .Toaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION pq�tq ATOS.Qn CENSUS TRACT <br /> Owner's Name SJF CO. Phone <br /> Address City ,9-3S-- <br /> Contractor's Name -. � �119�T License ° Phone <br /> TYPE OF WORK (Check) : NEW WELL '/!�' DEEPEN '/ I RECONDITION / / DESTRUCTION f�J <br /> PUMP INSTALLATION J J P16W REPAIR I / PUMP REPLACEMENT I-1 <br /> O they / <br /> DISTANCE TO NEAREST: SEPTIC TANK �j�• SEWER LINES PTT PRIVY <br /> SEWAGE DISPOSAL FIELD 2, CESSPOOL/SEEPAGE PIT - OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS _O <br /> Industrial Cable Tool Dia. of Well Excavation V <br /> Domestic/private _ Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing a <br /> Irrigation Gravel Pack Depth of Grout Seal C7 <br /> Other Rotary Type of Groutu�� _ <br /> Other Other Information <br /> C <br /> PUMP INSTALLATION: Contractor _ <br /> Type of Pump Jet H.P. <br /> PUMP REPLACEMENT: / State Work Done <br /> PUMP 7tEPAIR: / / State Work Done <br /> DFgTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe. Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the Satz. 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 /> informati is tr to the best of my knowledge and belief. <br /> SIGNED <br /> TITLE <br /> i .(DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> I PHASE I <br /> APPLICATION ACCEPTED .BY DATE �: �2 <br /> ADDITIONAL COMMENTS: LZ <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 2 <br /> 2 X <br /> # CALL I'OR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL IN ,TION. <br /> 5/731M. <br />