Laserfiche WebLink
M SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> US <br /> FOR OFFICE E: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 3_36 Y <br /> s THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> s < Date Issued &-(:2--7,3 <br /> Q° =' � + (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 aria the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION / i CENSUS TRACT <br /> Owner's Name <br /> Phone &P j p f�1?� <br /> Address f <br /> City <br /> Contractor's Name <br /> TYPE OF WORK (Check): NEW WELL /-7 DEEPEN /_/ RECONDITION /? DESTRUCTION /-� <br /> PUMP INSTALLATION / / PUMP REPAIR <br /> Other 4/ / PUMP REPLACEMENT /_7 <br /> — } <br /> i <br /> DISTANCE TO NEAREST: SEPTIC ;TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE <br /> TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial T Cable Tool Dia. of Well Excavation \ <br /> - Domestic/private i Drilled Dia. of Well Casing' a <br /> Domestic/public i Driven Gauge .vf Casing <br /> Irrigation ! Gravel Pack Depth of Grout Seal { <br /> Other I Rotary Type of Grout- <br /> Other <br /> rout -Other Other Information' � <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: <br /> /_7 State Work Done <br /> I <br /> PUMP REPAIR: State Work Done - <br /> _ <br />,DESTRUCTION OF WELL: Well Diameter, '- <br /> 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 lay work on a new well, I will furnish the San Joaquin Locaf' Health;Distriet a <br /> WELL DRILLERS REPORT of the well and notify `th'em efare `putting 'the well in use. The above <br /> information is true to the best of my knowledge and°,belief , -5 , <br />°SIGNED <br /> J TITLE <br /> .(DRAW PLOT PLAN ON REVERSE SIDE f <br /> PHASE I " FOR DEPARTMENT USE ONLY - <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> DATE <br /> PHASE II GROUT INSPECTION PHASE„III/FINAL INSPECTION, <br /> INSPECTION BY DATE INSPECTION BY DATE'�-' I"` <br /> CALL FOR A GROUT INSPECTION�PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br /> ` � <br />