Laserfiche WebLink
I SAN JOAQUiN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave, , Stockton, Calif. <br /> ' Teleph'one: (209) 466-6781 <br /> �PPLICATION FOR WELL CONSTRUCTION OR- PUMP PERMIT Permit No. _c <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued g [ ( v <br /> (Complete 'In Triplicate) <br /> i ,Application is;hereb made''°tb the San 'Joaquin -Local Health-District for aepermit 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 andRegulations of the San Joaquin Locsl` Health District. <br /> JOB ADDRESS/LOCATION f a CENS_U'S' TRACT <br /> t Owner's Nage <br /> Phone <br /> Address 0 City <br /> Contractor°s Name License # Phone <br /> TYPE OF WORK (Check) : NEW WELL /�`J DEEPEN / / RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / PUMP REPLACEMENT /_ <br /> Other <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 ..1 <br /> Industrial I Cable Tool Dia. of Well Excavation � i <br /> Domestic/private I Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation d Gravel Pack Depth of Grout Seal 1 <br /> Other 1 Rotary Type of Grout <br /> Other Other Information . <br /> r <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: I ' <br /> / / State Work Done <br /> PUMP REPAIR: / / State Work Done, <br /> ,DESTRUCTION OF WELL: Well Diameter ell— Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply withfall 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 REPORT of the we'll and notify them before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. <br /> SIGNEDVj,,j, ),y), pp <br /> r ' � L, u TITLE <br /> i (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY j <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: I <br /> PHASE II GROUT INSPECTION PHAS III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY <br /> I DATE <br /> CALL FOR A GROUT .INSPECTION.PRIOR .TO GROUTING AND FINAL INSPECTIO . <br /> E H 1426 i 7/72 1M <br />