Laserfiche WebLink
D� SAN `JOAQUIN LOCAL HEALTH DISTRICT <br /> 7-0 .0MCE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <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 work herein described. ' This application is made in compliance with. San Joaquin <br /> County Ordinance No. 1862 and� s and Regulations of the San Joaquin Local. Health District. ' <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone <br /> Address City <br /> a7A <br /> Contractor's Dame cense �hone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN RECONDITION /_/ DESTRUCTION /- <br /> PUMP INSTALLATION /WUMP REPAIR/ / PUMP REPLACEMENT /—T <br /> Other /-7 <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 r <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> c <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. 7 <br /> L <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP VPAIR: / / State Work Done <br /> DFRTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i <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 TITLE <br />' (DRAW PLOT PLAN ON REVERSE SIDE} <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED .BY 7/ _ DATE r,�cJ - <br /> ADDITIONAL M MENTS: <br /> PHASE II GROUT INSPECTION P II F NAL INSPECTIO r <br /> INSPECTION BY DATE INSPECTION BY DATE y <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> n 11 -1 if <br />