Laserfiche WebLink
SAN JOA IN,-LQCAL HEALTH DISTRICT <br /> Y <br /> FOR OFFICE USE. 1601 E. Hazelton Ave. , Stockton, Calif, <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> . � v r <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 I <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and' the Ru es d Regulations of the San Joaquin Local Health District. <br /> q',4-5-3 J /lid 7�Ct/djloscZ� <br /> JOB ADDRESS/LOCATION1 CENSUS TRACT <br /> Owner's Name j Phoned <br /> Address 3 S �.`a Z�� City � . <br /> Contractor's Name 7`/,�g 4,61A License #,2"y_Va Phone c,,-72F <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /-7 RECONDITION /-7 DESTRUCTION /- <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /-7Other i'/ / — — <br /> DISTANCE TO NEAREST: SEPTIC!TANK _ __f SEWER LINES PIT PRIVY <br /> SEWAGEIDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation /0— <br /> Domestic/private .; Drilled Dia. of Well Casing " <br /> - -- -Domestic/public Driven Gauge of Casing a� <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other !fir Rotary Type of Grout . " <br /> 1 Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. ] <br /> PUMP REPLACEMENT: / / Sate Work Done , <br /> — 1 <br /> PUMP REPAIR. / / State Work Done <br /> ,DESTRUCTION OF WELL: Well Diameter '� Approximate Depth <br /> Describe Material and4Procedure <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 or1regulating 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 /> (DKAT, PLOT AN ON REVERSE SIDE <br /> FOR DEPARTMENT`USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE CD 3 <br /> ADDITIONAL COMMENTS: <br /> PS <br /> I UT INSPECTION P I FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FORA INSPECTION PRIOR TO GROUTING AND FINAL INS ON. <br /> E H 1426 7/72 1M k 1 <br />