Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> l0"OFFICE USE: 1601 E. Hazelton Avei , Stockton, Calif. � <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. r 9P' I <br /> P <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> .,. i (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 •arid the Rules and Regulations /of the San Joaquin Local health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name / 3�y ;�: jcr�_ , Phone <br /> Address <br /> City C. <br /> Contractor's Name k �-� License # <br /> ' TYPE OF WORK (Check) : NEW WELL DEEPEN 4 _ / RECONDITION /_/ T DESTRtT TION /7 <br /> AL �i <br /> PUMP INSTALLATION k7 PUMP REPAIR /—/—PUMP PUMP REPLACEMENT /� <br /> 0 ther >./ <br /> J <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 <br /> Industrial 7 Z Cable Tool Dia. of Well Excavation ' C) # <br /> Domestic/private I Drilled Dia. of Well Casing <br /> Domestic/public 4 Driven ' Gauge of Casing <br /> Irrigation i Gravel Pack Depth of Grout Seal a} i <br /> Other J. Rotary Type of Grout{ <br /> 1 Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type 6f Pump i �d H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> _ F <br />.PUMP 'tEPAIR: / / State Work Done <br /> ,DFeTRUCTION OF WELL: Well Diameter .� Approximate' Depth - <br /> 1 Describe Material and Procedure _ <br /> I hereby agree to comply with all lams and regulations of the San Joaquin Local Health District #, <br /> and the State of California pertaining to or regulating well construction. . Within FIFTEEN DAYS 1 <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 Drell and notify thein before putting the well in use. The above E <br /> information is ue to t e best of my knowledge and belief. ' <br /> SIGNED _ - TITLE <br /> +I (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE <br /> = FOR DEPARTMENT USE ONLY <br /> T <br /> APPLICATION ACCEPTED BY DATE 73 <br /> ADDITIONAL COMMENTS: . 1 -- <br /> PItAS e II GROUT INSPECTION PHAS III/FINAL INSPECTION <br /> INSPECTION BY �zfteL DATE Y7- INSPECTION BY DATE 73 <br /> CALL FOR A GROUT INSPECTION. PRIOR TO .GROUTING AND FINAL INSPECTION. - <br /> .E .FI 1426 <br />