Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 0—T. OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -S3 tJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquiri'LocalHealth District for a 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 and Regulations of the San Joaquin Local. Health District. <br /> JOB ADDRESS/LOCATION '� CENSUS TRACT <br /> Owner's Name Phone 2,1 3 2 d <br /> Address 7 City <br /> Contractor's Name License J(71,12_211Phone <br /> TYPE OF WORK (Check) : NEW WELL IX DEEPEN/7 RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INS ALLATION / / PUMP REPAIR / J PUMP REPLACEMENT /? <br /> Other <br /> DISTANCE T4 NEAREST: SEPTIC TANKr SEWER LINESS�^(pJ' PIT PRIVY <br /> SEWAGE DISPOSAL FIELD&V- <br /> ,&XI CESSPOOL/SEEPAGE PIT . OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial _.Cabe .Tool Dia. of Well Excavation <br /> -XDomestic/privateDrilled 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 /> PUMP_ INSTALLATION: Contractor RnkO <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done ( <br /> PUMP '' EPAIR: / / State Work Done 1 - �► <br /> .DF1ZTRUCTION ELL: Well Diameter "R . Approximate Depth <br /> Describe Material and ro dure <br /> � - <br /> I hereby agree to comply with all laws anations of to6e San Joaq n Local He th Distri.ct <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 /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON, ,REVERSE SIDE7— <br /> FOR PARTME USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ` DAT <br /> ADDITIONAL COMMENTS: <br /> PiAeVE. ;IXROUT, INSPECTIO PHASE FI INSPECTIO <br /> INSPECTION BY TE INSPECTION BY DATE,2 2 <br /> Of f <br /> CALL FOR fGROUT -.INSPECTION PRIORTO GROUTING"AND .FINAL INSP IO . <br /> E H 1426 /10 7G��e�/ . -- - A 573 1M <br />