Laserfiche WebLink
F <br /> 4SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> I FOR OFFICE [SSE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. S-D3 LrJ <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued /�—_75 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construe <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_ . oaquin Laeal. aith iatrict. <br /> JOB ADDRESS/LOCATION• CENSUS TRACT <br /> Owner's Name ' s Phone <br /> i <br /> i <br /> Address �j? �, <br /> - City •� � <br /> i - • <br /> Contractor's Name _ / 5�7License # e&,� Phone �3- <br /> TYPE OF WORK (Check): NEW WELL DEEPEN / J RECONDITION /-7 DESTRUCTION /-7 <br /> i PUMP INSTAL ION / / PUMP REPAIR / / PUM REPLACEMENT /-7 <br /> Other �/ <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 i Cable Tool Dia, of Well Excavation <br /> Domestic/private t Drilled Dia, of Well Casing <br /> Domestic/public f Driven Gauge of Casing <br /> Irrigation i Gravel Pack Depth of Grout Seal <br /> Other ! Rotary Type of Grout <br /> 1 Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: <br /> / / State Work Done <br /> PUMP REPAIR: ,- / / State Work Done � <br /> r <br /> •DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> ~ T Describe Material and Procedure <br /> I hereby agree to comply withlall 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 ori 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 /> X'OnL*4� <br /> (DRAW PLOT PLAN ON REVERSE SID—E)i <br /> R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS IINSPECTION <br />`INSPECTION BY DATE INSPECTION BY ATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M } <br />