Laserfiche WebLink
JOAQUIN LOCAL HEALTH DISTRICT - ©n <br /> FOZFICE SE: 1601 E. Hazelton Ave. , Stockton, Calif.. <br /> p Tels hone: (204) 466-6781 <br /> ' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No <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 theR/ules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ,C CQQ� l/If L CENSUS TRACT <br /> Owner's Name �/6�t� ( Phone <br /> City f/6/C/ e A <br /> Address <br /> Contractor's Name �7� & Licenserftone��lr�`Z.Z <br /> TYPE OF WORK (Check): NEW WELL / DEEPEN RECONDITION /7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / I PUMP REPLACEMENT I_T <br /> . Other <br /> DISTANCE TO NEAREST: SEPTIC TALK SEWER LINES PIT .PRIVY <br /> SEWAGE DISP SAI. FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF ELL CONSTRUCTION SPECIFICATIONS <br /> �ndustrial Cable Tool Dia. of Well Excavation ACV <br /> omestic/private Drilled Dia. of Well Casing y <br /> Domestic/public Driven Gauge of Casing _ [.2 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout D <br /> Other _ _ Other lnforma ion O <br /> i <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: J / State Work Done <br /> PUMP REPAIR: / / State Work Done <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 /> k after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> M 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 TITLE /l Y <br /> (DRAW PIAT PLAN ON REVERSE SIDE <br /> ` <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I /D T /o aS` 7 � <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE J1 ROUT INSPECTION PHAS INSPECTION <br /> INSPECTIQN BY DATE INSPECTION BY DATE " 2' <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL IN <br /> E H 1426 7/72 1M <br /> i <br />