Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: V 1601 R. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> t , <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> In Triplicate) <br /> Application is hereby made to (Complete <br /> 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 <br /> _ CENSUS TRACT S <br /> t <br /> Owner's Name /,• Phone <br /> Address <br /> J -- City <br /> Contractor's Name License Phone�6 <br /> TYPE-UF'WORIC"�0}ieck):SEW'-WELL` ' / 3 �E$P`"EN� �`rRECONDITION /`T DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / Q PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC-�TANK _ SEWER. LINESf PIT PRIVY o� <br /> SEWAGE DISPOSAL FIELD "' CESSPOOL/SEEPAGE PIT OTHER Ca <br /> INTENDED USE ! <br /> TYPE OF WELL CONSTRUCTION SPECIFICATIONS z <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 /> PUMP INSTALLATION: Contractor <br /> Type of Pump H,P. <br /> 1 b_ <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP'REPAIR: 4�' State Work Done <br /> ESTRUCTION 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 /> SIGNED Pb . TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) u4G <br /> FOR DEPARTMENT,USE ONLY <br /> PHASE I <br /> i <br /> APPLICATION ACCEPTED BY 'w DATE <br /> ADDITIONAL COMMENTS: . <br /> PHASE I UT INSP CTION P9A9FvIII INAL INSPECTION <br /> INSPECTION BY � DATE INSPECTION BY DATE ` <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. Qs <br /> E H 1426 7/72 1M <br /> a <br />