Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: /X <br /> 160 E. Hazelton Ave. , Stockton , Calif. <br /> !� Telephone: . (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> iM <br /> THIS .PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date 'Issued <br /> (Complete' In Triplicate) <br /> Application is hereby,made' to the SanyJoaquin Local Health District for a permit to construct i <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/I' CATION <br /> 'nom CENSUS TRACT <br /> Owner.'s Name !I Phone <br /> Address �� �rLXl 1. City � <br /> I� 10 <br /> - _ i <br /> Contractor'siName p4;:l D License # Phone <br /> TYPE OF WORK (Check) : NEW WELL /5;� DEEPEN/-7 RECONDITION /7 DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /? <br /> Other / / <br /> DISTANCE TO DEAREST: SEPTIC TANK 2L,�L�i SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPEC ICATION <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 /> !M �� Other Other Information <br /> PUMP INSTALLATION: Contractor 001 c <br /> Type of Pump H.P. i <br /> PUMP REPLACEMENT: / / State Work Done <br /> _ 4 <br /> PUMP REPAIR: +� # <br /> State Work Done <br /> .DESTRUCTION 0 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 StateIIof 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 DRILLERSI1:REPORT of the well and notify them before putting the well in use. The above <br /> information xs . true to the best of my knowledge and belief. <br /> SIGNED i TITLE <br /> iM (DRAW_2-LOTELAN ON REVERSE SIDE) <br /> FOR DEPART NT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED B DATE <br /> ADDITIONAL COMMENTS: - <br /> PHASE II GROUfi :j�iSPECTION PHASE I/FINAL INSPECTION c <br /> INSPECTION BY D E ill INSPECTION BYDATE - - <br /> CALL FOR A:GROUT INSPECTION RIOR 0 GROUTItVG AND FINAL INSP ON. <br /> E H 1426 ! <br /> 4172 1M <br />