Laserfiche WebLink
i <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 'Or.;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> i <br /> Telephone:- � p (209) 466--6181 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <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 Local. Health District. <br /> JOB ADDRESS/LOCATION '7 ii� CENSUS TRACT s�� <br /> Owner's Name <br /> Phone <br /> Address City - r <br /> Contractor's Name <br /> License # Phone { <br /> TYPE OF WORK (Check) : NEWWELL 1.7 DEEPEN /_/ RECONDITION / % DESTRUCTION -%-7- <br /> PUMP INSTALLATION P6'MP REPAIR/ / PUMP REPLACEMENT /-7 <br /> Other l / <br /> DISTANCE TO NEAREST: SEPTIC. TA14K SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER y I <br /> I <br /> INTENDED USE EC <br /> _TYPE OF WELL CONSTRUCTION SPIFICATIONS <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 InfQrmation <br />` PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: <br /> / / tate Work bone <br /> PUMP 'tEPAIR: / / State Work Done s <br /> ,.,IDFRTRUCTION OF WELL: Well Diameter <br /> Approximate Depr-h <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 1 <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' ~4i <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE.) <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> � _ <br /> APPLICATION ACCEPTED .BY . DATE /D <br /> ADDITIONAL COMMENTS: <br /> PHASE 11 GROUT INSPECTION PHASE III/FINAL INSPECTION { <br /> INSPECTION BY DATE INSPECTION. BY DATE j <br /> CALL FORA GROUT INSPECTION.PRIOR TO.GROUTING AND FINAL- INSPECTION. <br /> E H 1426 <br />