Laserfiche WebLink
JOAQUIN LOCAL .HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazeltan.F-Pe.'",Stockt.on, Calif. <br /> Telephone :. (209) . 46b -6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS:,,PERMIT EXPIRES .1iYEAR, "ROM DATE ISSUED Date Issued 7S <br /> {Complete In. Triplicate) <br /> Application' is hereby made to the-fl San�7oaqu n `.Local Health District for a permit to construct <br /> is made in compliance with San Joaquin; <br /> and/or install the work herein described. This':-application <br /> County Ordinance No. -1862 and ,the:Rules and- Regulations-6f the San Joaquin Local Health District. <br /> CENSUS TRACT a <br /> JOB ADDRESS/LOCATION <br /> s T� Phone _ ` <br /> Owner's Name <br /> city c - <br /> Address <br /> Contractor's Name G <br /> License 4r 'hone <br /> TYPE OF WORK (Check} ; NEW WELL /�-YDEEPEN- ` /--RECONDITION 1/�'/ DESTRUCTION` <br /> PUMP INSTALLATION / / PUMP REPAIR '/ / -PUMP REPLACEMENT /? # <br /> Other <br /> 5 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD - CESSPOOL/SEEPAGEPIT . OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial : Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of WCas Casing <br /> f Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal _ <br /> Other Rotary Types f Grout ' <br /> 71 <br /> Other -Other Information <br /> Y / <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> f <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Doner <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 REPO R -the well-and-notify -them-before putting the well in-use,-- -The above <br /> inform to the best of my k wledge and belief. <br /> TITLE <br /> SIGNED <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ) <br /> APPLICATION ACCEPTED BY ,� DATE �" r <br /> ADDITIONAL COMMENTS- Q <br /> PHASE II <br /> PHA E II ROUT INSP TIO r / IN INSPECTI <br /> INSPECTION BY DATE �o INSPECTION BY DATE 7 <br /> CALL FOR A.GROUT INSPECTION PRIO TO GROUTING AND FINAL INSPECTION. 4/72 1M <br /> E H 1426 j10 'c 5 ; fl 7- 111 <br />