Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT '• <br /> FOR 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 )z. <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 the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 31 �' CENSUS TRACT <br /> Owner fs Name Phone" <br /> Address .R Cityp <br /> Contractor's Name License #/ <br /> TYPE OF WORK (Check) : NEW WELL /-7 DEEPEN /_/ RECONDITION /-7 DESTRUCTION /-7 <br /> AL <br /> PUMP INSTLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <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 "" r CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casingw <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION. Contractor k� <br /> Type of Pump H.P. ! <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Works Done e <br /> wf„ <br /> ttl�- �a -40v� <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 /> 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 knowl g an elief. <br /> SIGNED TLE _ ' <br /> (DMW RLOT FLA ON REV SE SIDI) i <br /> PHASE I R DEPARTMENT USE ONLY a <br /> APPLICATION ACCEPTED BY DATE 15 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1MI �"' <br />