Laserfiche WebLink
C SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> For.SOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.,7 <br /> R <br /> THIS PERMIT EXPIRES 1. YEAR FROM DATE ISSUED Date Issued <br /> 1 (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 Jaaqui <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> .TOB ADDRESS/LOCATION CENSUS TRACT <br /> f <br /> . 'Owner's Name Phone9Yy" 1(3 9,Q <br /> _ I <br /> Address 3 c)a, �i- - City <br /> ' <br /> 'Contractor's Name � � �.��•� � icense <br /> TYPE OF WORK (Check) : NEW WELL /� DEEPEV / . RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION � P-6W REPAIR / / PUMP REPLACEMENT 1-7 <br /> Other -/ <br /> / <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_SPECIFI ATIONS L <br /> Industrial Tool Dia. of Well Excavation 1 <br /> I <br /> stic/private Drilled Dia. of Well Casing 1 4D <br /> Domestic/public Driven Gauge of Casing C---N <br /> i Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout � t <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> { Type of Pump H.P. <br /> PUMP REPLACEMENT: f / State Work Done - _ -- -- <br /> F PUMP, UPAIR: / / State Work Done <br /> DFgTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i <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 knowledge and belief. <br /> x SIGNED TITLE . <br /> Y (DRAW 'LOT PLAN ON REVERSE SIDE) <br /> . FOR D gPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �.�. C� F �. DATE <br /> ADDITIONAL COMMENTS: 1 <br /> PHAS I GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY : DATE 1D -A.3 .t INSPECTION BY DATE ate-,-, ? <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. � <br /> r.2h 5/731M <br />