Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> I OT..OF FILE USr,: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,ZLy-2�D4) <br /> THI�JERMIT EXPIRES 1 YEAR FROM DATE -ISSUED Date Issued <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 Ordjnaan��. 1862 and the Rules and Regulations of the San Joaquin Local Health District, <br /> 1 <br /> JOB ADDRESS/LOCATION 1r r CENSUS TRACT �` 5_0 <br /> Owner's Name Phone, �i Q <br /> Oin �y I <br /> Address '" t � — City . r <br /> Contractors Name l Licensef , -Phone 3 <br />: TYPE OF WORK (Check): NEW WELL /W/ DEEPEN I I RECONDITION / / DESTRUCTION /? I <br /> PUMP INSTALLATION { / PUMP REPAIR '/ I PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SE14AGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> 43 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial. Cable Tool Dia. of Well Excavation <br /> Domestic/private -Y Drilled Dia. of Well Casing <br /> Domestic/pukic - Driven Gauge of Casing <br /> _ Irrigation t Gravel Pack Depth of Grout Seal _ <br /> Other Rotary Type of Grout .. <br /> Other Other Information •. <br /> PUMP INSTALLATION: :.-'Contractor <br /> Type of Pump H,P. <br /> PUMP. REPLACEMENT: { / State Work Done <br /> T <br /> PUMP TtEPAIR: ,r. / / State Work Done - " '' - -. - - <br /> !,�TRUCTION OF WELL: Well Diameter `'.. Approximate Depth <br /> '. Describe Material and Procedure , <br /> I hereby agree to `complyjwith all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well''construction. Within-71I'TEEN DAYS <br /> after completioh"'pf .my work on a new well, I will furnish the San Joaquin Local�Realth District a <br /> WELL DRILLERS REPORT `o.f .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 /> V <br /> SIGNED . TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> F.QRj PARTMENT USE ONLY <br /> v PHASE I •`':.' - <br /> APPLICATION ACCEPT DATE - 7V <br />' ADDITIONAL COMME ' y j Y r .��•.. - . sr,+ !° c st _ , 'r=s <br /> ROUT INSPECTION V . PHAS I F %NAL INSPECTION <br /> INSPECTION BY DATE ` INSPECTION BY --- DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO, GRO TING AND FINAL INSPECTION. <br /> -rc;/7 iim <br />