Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.," <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date lssued ,Z, a-,y � <br /> (Complete In Triplicate) <br /> Application is hereby 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 /> .LOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone ca060 <br /> Address � s( <br /> City <br /> Contractor's Name License # / -373 Phone 44-fG,Z <br /> TYPE OF WORK (Check): NEW WELL /-7 DEEPEN /_� RECONDITIONS/� DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT— /-7 <br /> Other /-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL- FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> ti. <br /> INTENDED USE TYPE OF WELL j F CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool" Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge. of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other ' . , ..y. Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: <br /> / / State Work bone <br /> PUMP REPAIR: / / State Work Done C <br /> RESTRUCTION 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 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 l ,1 TITLE <br /> (DRAW'PLOT PLAN ON REVERSE SI <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> � . <br /> APPLICATION ACCEPTED BY-1-1, DATE - Z <br /> kDDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL. INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> f Tv <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 Y 7/72 1M <br />