Laserfiche WebLink
y SAN JO <br /> AQUIN LOCAL HEALTH DISTRICT <br /> '-FOL OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 rj <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 <br /> THIS PERMIT EXPIRES i YEAR FROM DATE ISSUED Date Issue <br /> d��J� <br /> (Complete In Triplicate) <br /> Application is hereby made to the. San Joaquin Local Health District for a permit to constructand/or install the work herein described. ' This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and t# Rules.and� Regulations of the San Joaquin Local Renith District. <br /> .TOB ADDRESS/LOCATIONf o A CENSUS TRACT <br /> Owner's Name Phone <br />` Address ) City <br /> Contractor's Name License d Phon � k�al5"` <br /> •_-�,..ti_._ -�. _ _� - ----�--- -� .- ►;ter -� <br /> TYPE OF WORK (Check): NEW WELLDEEPEN/ / RECONDITION /_/ DESTRUCTION /? <br /> PUMP INST�TION / / PUMP REPAIR / PUMP REPLACEMENT /7 <br /> _ Other / --- <br /> DISTANCE TO NEAREST: SEPTIC TANK SE�,TER LINES PIT PRIVY <br /> it SEWAGE, DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> y Domestic/private gilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> 71) <br /> Irrigation 1 Gravel Pack Depth of Grout Seal <br /> Other. Rotary Type of Grout <br /> f Other Other Information <br /> PUMP INSTALLATION: Contractor y <br /> Type of Pump H.P. . <br /> I � <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP "tEPAIR: / / —S- taeW&r—IC' <br /> .DF-qTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations o.f'"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 knowledge and belief. <br /> SIGNED TITLE <br /> t (DRAW PLOT PLAN ON REVERSE"'SID ) <br /> 0 ARTMENT USE ONLY <br /> PEASE I ;K. <br /> APPLICATION ACCEPT Y DATE to -,7 <br /> ADDITIONAL COMME , <br /> P ROUT INSPEC ION P / AL INSPECTION <br /> INSPECTION BY ROUT <br /> 7 . INSPECTION,_BY DATE -Z S� <br /> . CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. � <br /> E H 1426 E�/7-1Yu <br />