Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ;COT`. OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7.5'=2 74d <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> ;i (Complete In Triplicate) <br /> Application is %ereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install.11 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 /> .TOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> Owner's Name p Phone �' � 2(a3 0 <br /> Address <br /> �o City <br /> WOODS ; <br /> Contractor's Name License Phone r <br /> TYPE OF WORK (Check) : NEW WELL /—/ DEEPEN`/,_t-RECONDITION / / DESTRUCTION /_7 <br /> 'p AL <br /> PUMP INSTLATION REPAIR /—/—PUMP REPLACEMENT 1-7 - <br /> Other <br /> -7 -Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED`USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial �L,, Oable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing U <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> 7 WOODS <br /> PUMP INSTALLATION: Contractor WELL DRILLING <br /> Type of Pump H.P. <br /> ! <br /> PUMP REPLACEMENT: / / State Work Done <br /> ii <br /> r 'UMP UPAIR: ;I, / /. State Work Done <br /> ,DFsTRUCTION OF,WELL: Well. Diameter Approximate Depth � � J <br /> !� Describe Material and Procedure <br /> Y hereby agreelto 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 neer 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 /> e _ <br /> SIGNED ,o , TITLE <br /> (DkKW PLOT PLAN ON REVERSE SID <br /> FOR DEi'ARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: (1 <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY !I DATE INSPECTION BY - DATE <br /> CALL FOR A 'GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 5/731M <br />