Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> `Telepylone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> r <br /> THIS PERMIT EXPIRES 1' YEAR FROM DATE ISSUED Date Issued <br /> Application is hereby made to the San (Joaquin eLo alrHealth District for aper ZOOM <br /> permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862.. and the Rules Regulations of the San Joaquin Local Health District. <br /> JO ADDRESS LOCATION ' Lx <br /> _ CENSUS TRACT -� <br /> Owner's Name - <br />' Phone 4)} Ll <br /> Address `�' <br /> Contractor's Name <br /> License PhoneJ33 <br /> i <br /> TYPE OF WORK (Check) : NEW WELL ' f <br /> 17 DEEPEN / RECONDITION /77� DESTRUCTION /_7 <br /> PUMP INSTALLATION /PUMP REPAIR% % PUMP REPLACEMENT r <br /> f <br /> Other ,/—/ -- /? I <br /> � I <br /> DISTANCE TO NEAREST: SEPTICITANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ; <br /> -- -. Industrial S Cable Tool Dia. of Well Excavation <br /> Domestic/private ! Drilled Dia, of Well Casing i <br /> Domestic/public Driven Gauge of Gasing r <br /> Irrigation t Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> w <br /> PUMP INSTALLATION: Contractor L-Y� _ <br /> .Type of Pump H.P. <br /> PUMP REPLACEMENT: ` M <br /> State Work Done <br /> PUMP REPAIR: / / State Work Done <br />,DESTRUCTION OF WELL: Well Diameter <br /> - Approximate Depth <br /> Describe Material and Procedure j <br /> � l c <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;-l--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(�- the best of my knowledge and. belief, <br /> SIGNED TITLE_ c' <br /> (DRAW ..P.LOT-PLAN--ONw REVERSE SIDE} _ <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY � -� <br /> ADDITIONAL COMMENTS: DATE - 7-7,Y <br /> PHASE II GROUT-INSPECTION— <br /> INSPECTION <br /> INSPECTION BY DATE INSPECTION BY <br /> CALL FOR A GROUT INSPECTION .PRIOR TO GROUTING=AND`VINAL INSPECTION. <br /> E H 1426 7/72 IM <br />