Laserfiche WebLink
r <br /> °N JOAQUIN LOCAL HEALTH DISTRICT' <br /> FOR OFFICE USE: <br /> 1/ 1601aL. h'azelton Ave. , Stockton, Callf. <br /> TelephoL.'e: (209) 466-6781 <br /> APPLICATION FOR WELL (,,NSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEOi FROM DATE ISSUED Date Issued -TS- <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 Joaquii <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> a <br /> Owner's Name Phone��y•-�� ��'� <br /> C Address City <br /> Sontractor's Name Licenses `� Phone-7 1 l6- <br /> / <br /> TYPE OF WORK (Check) : NEW WELL / Di EPEN / / RECONDITION /_/ DESTRUCTION /-' <br /> PUMP INSTALLATION _/_% PUMP REPAIR / / PUMP REPLACEMENT <br /> Other — <br /> )ISTANCE TO NEAREST: SEPTIC TANK (J SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL <br /> CONSTRUCTION SPECIFICATIONS � <br /> Industrial Cable Tool Dia. of Well Excavation---f-';-?--- <br /> �r <br /> �mestic/private � Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout E@al <br /> Other Rotary Type of Grout <br /> Other Other Information -- <br /> 'UMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br /> q <br /> UMP REPLACEMENT: / / State Work Done <br /> UMP REPAIR: / / State Work Done <br /> ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> nd the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> fter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> ELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> nformation is true to t e best of my knowledge and belief. <br /> CGNED \�� �--\ TITLE ON) <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> 1ASE I <br /> ?PLICATION ACCEPTED BY DATE /c Q <br /> )DITIONAL COMMENTS: r S" cfGrc <br /> PHASE II GROUT INSPECTION P SE <br /> �/FINAL INSPEC ION <br /> 'SPECTION BY gtU DATE i � INSPECTION B DATE 3 ' S <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 _ _ <br />