Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USSE:E: 1601 E. Hazelton Ave. , Stockton, Cal-if. <br /> r Telephone: (209) 466-6781 <br /> b APPLIi CATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.�o?/ p <br /> i <br /> i THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Essued.lm7/S-P L <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 CENSUS TRACT <br /> Owner's Name Phone <br /> Addresszza ` <br /> City <br /> Contractor's Name ! License # Phone <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN / / RECONDITION /_7 DESTRUCTION <br /> PUMP INSTALLATION / /. PUMP REPAIR / / PUMP REPLACEMENT/_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC )TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPO L 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 i Gravel Pack Depth of Grout Seal <br /> Other I Rotary Type of Grout <br /> I Other Other Information F <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ,pESTRUCTION OF WELL: Well Diameter 4- <br /> _— G Approximate Depth - <br /> Describe Material and Procedure <br /> f <br /> I hereby agree to comply withiall I ws 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 /> f <br /> SIGNED <br /> TITLE <br /> (DRAW FdjW PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATEj6r=,� <br /> ADDITIONAL COMMENTS: <br /> PRASE II GROUT INSPECTION PHAS III/FIIJAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY • D / 1 <br /> r <br /> CALL FOR A GROUT INSPECTION.PRIOR TO GROUTING AND FINAL INSPECTION. � <br /> E H 1426 g7/72 1M <br />