Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> O .:OI'PTC USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 y <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No 7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued�-�-ZL <br /> (Complete In Triplicate) <br /> Application is hereby rude to- the San Joaquin Local Health District for <br /> compliancepermit <br /> to construct <br /> th San Jaaqulr► .I <br /> and/or install the work herein described. ' This application is made n <br /> County Ordinance No. .1862 and the Rules and Regulations of the San Joaquin Local Health District. f <br /> CENSUS TRACT ` <br /> JOB ADDRESS/LOCATION <br /> r <br /> C�/� l� f'!/ of /� /1!� Phone <br /> Owner's Name ,�J } <br /> Address . <br /> Contractor's Name l <br /> License 4� Phone� � �3 <br /> f , <br /> TYPE OF WORK (Check) : NEW WELL DE <br /> / / DEEPEN/9 RECONDITION / / DESTRUCTION / <br /> PUMP',JNSTALLATION f / PUMP REPAIR I / PUMP REPLACEMENT 17 <br /> other',-/ I <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESSEWAGE DISPOSAL FIELD <br /> CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USETYPE WELL CONSTRUCTION SPECIFICATIONS <br /> Cable Too <br /> l' Dia. of Well Excavati <br /> Industrial <br /> o <br /> Domestic/private } Drilled Dia. of Well Casing <br /> -' - <br /> Domestic/public Driven Gauge of Casing <br /> i <br /> 1,---Irrigation Gravel. Pack Depth of Grout Seal. <br /> IIII Other Rotary Type of Grout Ca <br /> 4 otherOther Information <br /> I <br /> I <br /> PUMP INSTALLATION: Contractor H.P. " <br /> Type4 of Pump <br /> i{ PUMP REPLACEMENT: / / State Work Done <br /> i <br /> 1 State Work Done <br /> � PUMP 'REPAIR: <br /> i Approximate Depth <br /> ,PFQTRUCTION OF WELL: Well Diameter <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 well 'construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I wi11 furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of rhe 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 /> 1 TITLE <br /> SIGNED <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED -BY <br /> ADDITIONAL COMMENTS: F PHASE I /FINAL INSPECTION <br /> PHASE II GROUT INSPECTION INSPECTION B DATE <br /> INSPECTION BY I DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. 5/731M <br /> r — , /_n 6 <br />