Laserfiche WebLink
.Qi0 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Fnf ©��itE USE 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. a <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ` <br /> (Complete In Triplicate) <br /> Application is hereby made to the .San Joaquin Local Health District for a permit to construct <br /> and/or install the cork 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 Q rUAZ"� <br /> CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address City <br /> Contractor's Name cense Phon4? f <br /> TYPE OF WORK (Check): NEW WELL N <br /> � DEEPEN 1 RECONDITION /—/ DESTRUCTION /_7 <br /> PUMP INSTALLATION J / PUMP REPAIR / / PUMP REPLACEMENT /_` <br /> Other /_7 n ` <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 /> Tndustrial Cable Tool Dia. of Well Excavation 17 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing s <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary----- .�;. Y Type of Grout 40 <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP UPAIR: / / State Werk Done _ <br /> ,DFRTRUCTION 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 <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 <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> --- <br /> APPLICATION ACCEPTED BY DATE / •r�- <br /> ADDITIONAL COMIENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY RATE �� <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 5/731M <br />