Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> HIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued-g'G1 -7 <br /> (Complete In Triplicate) /�3 (0 <br /> licatian is hereby made tdIrthe San Joaquin Local Health District for a permit to construct <br /> APP + <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 ` th Rul �ulations of the <br /> San Health District. <br /> - .Z.ys=��' 'rt°"� CENSUS TRACT <br /> JOB ADDRESS/LOCATION . <br /> ' .Phone <br /> Owner's 'Name J - -- <br /> Address _. 0�- ..S �"? .- City <br /> Contractor's Name <br /> License # /� Phone 7G a <br /> I. TYPE OF WORK (Check): NEW WELL / / DEEPEN_/�/ RECONDITION /� DESTRUCTION / 'Z <br /> PUMP ';INSTALLATION / / PUMP REPAIR LK/ PUMP REPLACEMENT r_/_7 N`3 <br /> other! /—/ ' <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT CESSPOULJSEEPAGIVY <br /> PIT OTHER <br /> SEWAGE DISPOSAL :FIELD <br /> ► INTENDER USE TYPE OF tnTELL 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 /> Irrigation I Gravel Pack Depth"of Grout Seal <br /> Other Rotary Type of-Grout <br /> Other Other Information <br /> f 1 <br /> I PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. �G _ <br /> { PUMP REPLACEMENT: / State Work Done <br /> PUMP REPAIR: / State Work Done � '+ <br /> r App roximate Depth <br /> ESTRUCTION OF WELL: Well-Diameter <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 knowledge and belief. <br /> ITLE <br /> ' SIGNER <br /> (D W L T PLAN ON RE SE SIRE <br /> 1 OR DEPARTMEFT USE ONLY <br /> + PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> . ADDITIONAL COMMENTS: PHASE III FINAL INSPECTI0 <br /> PHASE II GROUT INSPECTION DATE <br /> INSPECTION BY i DATE INSPECTION BY <br /> CALL FORA GROUT INSPECTION .PRIOR TO GROUTING AND FINAL INSPECTION. 7J72 1M <br /> E H 1426 <br />