Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton-Ave.' ' Stockton, Calif. { <br /> Telephone:. <br /> (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. J <br /> erxo <br /> THIS PERMIT EXPIRES 1 YEAR FROM. DATEISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby .made to the San Joaquin Vocal Health District for, a permit to Construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin i <br /> County Ordinance No. l 1862 and the-Ruan Regulations f theJoaquin Local Health District. <br /> s CENSUS TRACT . S 7 I <br /> JOB ADDRESS/LOCATION - "d <br /> i' Phone <br /> Owner.'s Names <br /> City <br /> Address <br /> T �License �,2/I" Phone •? <br /> Contractor's Name <br /> TYPE OF WORK {Check} : NEW WELL / / DEEPEN -/ / RECONDITION-/7 -DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR .X UMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 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 <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 /> j <br />} PUMP INSTALLATION: Contracto4Work <br /> k Type of P H.P. <br /> f _ <br /> PUMP REPLACEMENT: / / Stat ;4;;e <br /> i <br /> PUMP REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter ..� Approximate Depth <br /> 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 of my knowledge and belief. <br /> ' <br /> TITLE <br /> SIGNED ` <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY <br /> DATE INSPECTION BY f:� DATE ' <br /> CALL_ FORrA GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. 4/72 1M <br /> E H 1426 ' <br /> I <br />