Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT f <br /> F0F.rOFF10E USE. 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. i �r,J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ,e!_�� _74 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/oar 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 `� �'Ca!� IV 2#--' CENSUS TRACT ,�• <br /> Owner's Name -Phone <br /> 41 <br /> Address 0 A,4 City <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check): NEW WELL _�EEPEN ./_/ RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION / PUMP REPAIR J / PUMP REP EMEN� /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TAiNK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> rrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: ontractor <br /> Type of Pump H.P. A.1(47 <br /> i PUMP REPLACEMENT: J / State Work Done <br /> i <br /> ,PUMP TEPAIR: State- Work Done <br /> 4 <br /> DFgTRUCTION 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 />'s WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is true to the be2t of my knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDT) <br /> D MENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPua Y 9tn DA E --y`—= <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPEC'T'ION_ P E I/ INSPECTI 1 <br /> INSPECTION BY DATE INSPECTI X DATE <br /> CALL FOR A GROUT INSPECTION PRION TO GROUTING AND FINAL INSPECTION. <br />` E H 1426 5/731M <br />