Laserfiche WebLink
SAN- JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF_OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <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 Wade 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 Regulationsofthe San Joaquin Local Health District. <br /> I Yid( CENSUS TRACT <br /> JOB ADDRESS/LOCATION <br /> Owner's Name Phone <br /> ei <br /> Address _ t Jtt city <br /> Contractor's Name License #/k7k{ PhoneZ~ -� <br /> TYPE OF WORK (Check) : NEW WELL -/ DEEPEN '/ / RECONDITION-/ / DESTRUCTION r7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT I <br /> F, Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY � <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER V <br /> INTENDED USE (TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Tndustrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> I <br /> Other Other Information <br /> I <br /> PUNT INSTALLATION: Contractor <br /> 4 Types of Pump H.P. / <br /> iQ <br /> PUMP REPLACEINENT: / State Work Done D : <br /> 72 <br /> ' r <br /> a PUMP 'tEPAIR: / / State Work Done <br /> I <br /> DR-TRUCTION 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 /> :.; <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 jedga <br /> lief. <br /> SIGNED SLE(D W �RERSE SIDE <br /> EPARTMENTUSE ONLY <br /> 4; PHASE I <br /> f' DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL CO.RMENTS: <br /> I: PHASE IZ GROUT INSPECTION PHA E III FINAL INSPECTIO <br /> INSP1sCTION BY DATE INSPECTION BY DATE <br /> CL FOR-A CRO;'"' .sNSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> , 5/731M <br />