Laserfiche WebLink
Yp/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F5L.'o ria us E: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ��/6�� M <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 Vocal Health District. <br /> .TOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name <br /> Phony d <br /> Address l ��� <br /> City . . ®�I 1,014 <br /> Contractor's Nave <br /> License Phone <br /> TYPE OF WORK (Check): NEW WELL '// / DEEPEN /_/ RECONDITION /_/ DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TAi�TK 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 -V <br /> Domestic/private Drilled Dia, of Well Casing <br /> Irrigation Driven 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 'ZI <br /> I <br /> Type of Pump H.P. . <br /> PUMP REPLACEMENT: / / State Work Done $ <br /> PUMP 'REPAIR: State Work .Done <br /> DF-4RUCTION OF WELL: Well Diameter Approximate Depth r <br /> Describe Material and Proce urd e <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 t <br /> information is true to the best of my knowledge and belief. <br /> SIGNED TITLE <br /> (DRAFT PLOT PLAN ON REVERSE SIDE) <br /> PHASE I r. - � _ .__ <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED -BY e DATE � - <br /> ADDITI©NAL COMMENTS: <br /> PHASE II GROUT INSPECTIONIf PHASE III/FINAL INSPECTIO <br /> INSPECTION BY DATE ,� INSPECTION BY eeVODATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 <br /> /7�iU <br />