Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT ' <br /> FOL OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 <br /> 1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made tolthe San Joaquin Local Health District for a permit to 'coinstruct <br /> and/or install the work herein described. ' This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and'ithe Rue a d Regulatio of the San Joaquin Local Health Dis�rict. <br /> JOB ADDRESS/LOC=ON _ i1 ic�r� flUS TRACT <br /> Owner's Name �� V � -�� Phone'`- <br /> Address �-- A45) 11 l J�l�7c�' City ' `'►� <br /> Contractor's Name U �� License #1 <br /> TYPE OF WORK (Check): NEW WELL /% DEEPEN '/ % RECONDITION 1 / DESTRUCTION . <br /> PUMP INSTALLATION REPAIR 6i� PUMP REPLACEMENT I-T <br /> Other 'J% <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> 1 <br /> ( � t <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS O <br /> Induptrial l Cable Tool Dia. of Well Excavation . <br /> Domestic/private �i Drilled Dia. of Well Casing <br /> Domestic/public t Driven Gauge of Casing [ <br /> Irrigation f Gravel Pack Depth of Grout Seal <br /> Other ! Rotary Type of Grout <br /> t Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'iEPAIR: l State Work Done <br /> DF-,TRUCTIDN 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 we11 "canstruction. Within FIFTEEN DAYS <br /> new well furnish the San Joaquin Local Health District <br /> after completion of my work an a , I will <br /> WELL DRILLERS REPORT of the well and notify theta before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. <br /> SIGNED TITLE _ �[},.,La4z ,z -- - <br /> �t (DRAW PLOT PLAN ON REVERSE SIDE) <br /> i FOR DEPARTMENT USE ONLY <br /> PHASE' I I <br /> APPLICATION ACCEPTED DATE <br />'E ADDITIONAL- NTS , <br /> f PHASE II GROUT INSPECTIONPHASE IT I SPECTIDN <br /> 1 INSPECTION BY DATE, INSPECTIONBY -`� �� ATE <br /> CALL FORA GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPEC ON. <br />