Laserfiche WebLink
/ �� -� ••F <br /> y SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR 6FVICE 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 Issued j>3 <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 /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> Owner's Name Phone <br /> Address 2 ' <br /> City ,�,, <br /> Contractor's Name <br /> License # QZ 00 t Phone G,44-6317 <br /> TYPE OF WORK (Check) : NEW WELL !7I DEEPEN /-7 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP 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 Cable Tool Dia. of Well Excavation S�Li <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 -- X Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> a ti <br /> PUMP REPLACEMENT: /_7 State Work Done <br /> PUMP REPAIR: /_7 State Work Done <br />,DESTRUCTION 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 TITLE <br /> (D OT PLAN ON REVERSE SIDE) <br /> PHASE I DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY Ze LN^^ DATE <br /> ADDITIONAL COMMEN <br /> P 0 I P I PHASE AL INSPECTION <br /> INSPECTION BY AT --INSPECTION BY DATE <br /> CALL FOR A T SPECTION 11R TO GROUTING AND FINAL INSP <br /> E H 1426 7/72 1M <br />