Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0 OFFICE USE. 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT jPermit No. <br /> c - THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is h reby 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 the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION W�jQ r da� CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address Sam e . City <br /> Contractor's .Name L� &Z2 <br /> License honed <br /> ti '^4 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION %T�ti DSTRUCTION''f�'J` <br /> PUMP INSTALLATION / / `_PUMP REPAIR PUMP �REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER, LINES PIT PRIVY.,, <br /> SEWAGE DISPOSAL FIELD : CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE-DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL r: CONSTRUCTION SPECIFICATIONS , <br /> Industrial Cable Toolx Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casin <br /> g: - <br /> g: <br /> Domestic/public � .- Driven Gauge of Casing <br /> Irrigation Gravel. Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal i Other Other Information <br /> Geophysical i h _ Surface Seal Installed By: <br /> PUMP INSTALLATION Contractor <br /> Type of Pump <br /> H.P. <br /> i - <br /> PUMP REPLACEMENT: / / State Work Done <br /> 5 � - <br /> PUMP .REPAIR: i State Work Done <br /> DESTRUCTION OF -WELL: Well Diameter Approximate 'Depth <br /> "I Describe Material and Procedure <br /> I hereby agree --to comply with all laws and regulations of the San Joaquin Local Health District <br /> t 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 i t e to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO TING AND A FINA INSP CTIO <br /> SIGNED TITLE - Of <br />+ OT PLAN ON REVERSE SID ) <br /> OR DEPARTMENT USE ONLY <br /> 4 <br /> PHASE I :t_ <br />' APPLICATION,ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> ' PHASE II G - TION PHASE III/FINAL I SPECTION <br /> INSPECTION BY ATE INSPECTION BY /t DATE l6 -3 -77 <br /> 2M <br />