Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F—TO-E oP ICE USE: .1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �1�-�-/S- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued,/e2- fig' <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or instal, 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 /> .TOB ADDRESS/LOCATION S , _ CENSUS TRACT <br /> Owner's Name Phonec5__: 9 �j <br /> Address City <br /> Contractor's Name License 4iA4 <br /> Z04YIhone 441-4922,!), <br /> - w <br /> TYPE OF WORK {Check} : NEW WELL ,g DEEPEN / / RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /? rt. <br /> Other <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 Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <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 /> r <br /> PUAT INSTALLATION: Contractor C ` <br /> Type of Pum H.P. • <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP UPAIR: / / State Work Done <br /> ,DFSTRUCTION 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 i <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 tr a to th best of my knowledge and belief. <br /> SIGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT ONLY <br /> PHASE I ��� <br /> APPLICATION ACCEPTED BY DATE�� <br /> ADDITIONAL. COMMENTS: <br /> PFIASE II GRfl T INSPECT N PHASE III/FINAL INSPECTION <br /> INSPECTION BY ,�, DATE �/ INSPECTION BYATE <br /> ALL 1FOR <br /> 2b A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. . <br /> �► a 5/731H,�� <br />