Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ` Calif. <br /> F0�'.�OL'I ICE 'US E: 16{}1 E. Hazelton Ave. , Stockton, <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Pexmit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUER Date issued <br /> (Complete In Triplicate) <br /> Application is hereby made tolthe San Joaquin Local Health District for a permit to constzucC <br /> and/or install the work herein described. ' This application is made in compliance with Saxe Joaquin ,the <br /> Health <br /> County Ordinance No. 1862 andl the Rules and Regulations of the San Joaquin.057 1 . 070- 3�vs rict. <br /> �y <br /> _�g cENsus TRACT <br /> JOB ADDREss/LOCATION <br /> Phone d ado <br /> owner's Name ` <br /> City .0 <br /> Address <br /> T ,f License J Phone <br /> Contractor's -Name <br /> d <br /> TYPE OF WORK. (Check) : NEW WELL DEEPEN /_/ RECONDITION /_{ DESTRUCTION /�T <br /> PUMP INSTALLATION .4 PUM'MP REPAIR / / PUMP REPLACEMENT 1_7 ` <br /> other J / <br /> F 1 <br /> f DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> r � <br /> TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE <br /> G r <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Brined Dia. of Well Casing <br /> Domestic/private <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 /> �x <br /> PUAiP INSTALLATION: Contractor. H.P <br /> G Type of Pump ` <br /> 1 . <br /> PUMP REPLACEMENT: / State Work .Dona <br /> PUMP REPAIR: / / :IState Work Done <br /> k � <br /> Approximate Depth <br /> DF"TRUCTION OF WELL: Well Diameter # <br /> Describe Material and Procedure <br /> A ; <br /> . I hereby agree to comply with all laws and-regulations of the Sdn,Joaquin Local Health Distract <br /> and the `$tate of California pertaining to`�or regulating well 'construction. Within FIFTEEN DAYS <br /> well, I will furnish the San Joaquin Local Health District a <br /> after completion of my work on a new <br /> 14ELL DRILLERS- REPORT of ,the well and notify them before putting the>well in use. The above <br /> information 's true o the best of my knowledge and 9. <br /> TITLE <br /> SIGNER <br /> (DRAW PLOT PLAN ON REVERSE SIRE) <br /> s <br /> FdR DEPARTMENT USE ONLY <br /> } DATE ; . - 7 - <br /> i PHASE I � � .� ��, ., �, a <br /> APPLICATION ACCEPTED' $Y <br /> ADDITIONAL COMMENTS', .,. PHASE III/FINAL INSPECTION <br /> PHASE II GROUT INSPECTION INSPECTION BY DATE <br /> INSPECTION BY DATE oZ 'o5 <br /> TO GROUTING AND FINAL INSPECTION. <br /> CALL FOR A GROUT INSPECTION PRIOR 5/731m <br />