Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT ��3'� 7 <br /> FOR OFFICE USE <br /> 1601 E. Hazelton Ave, , Stockton, Calif. M <br /> Telephone: (209) 466-6781 3 4t� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THI5 PERMIT EXPIRES 1- YEDate Issued FROM DATE ISSUED 1 -7 <br /> . (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District made furin ca per ncetwithnSanuJoaquinE <br /> mi <br /> and/or install the work herein des <br /> F <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> j <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION . . <br /> ' Phone <br /> Owner's Name <br /> City <br /> Address <br /> License # — Phone <br /> Contractor's Name <br /> 00 <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN f PUMPRREEPAIRI/N// P�DESTRUCTION <br /> Emmd— f7 <br /> PUMP INSTALLATION /� <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES s— PIT PRIVY <br /> E SEWAGE DISPOS FIELD � CESSPOOL/SEEPAGE PIT OTtER — <br /> q <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS NNJ <br /> Industrial Cable Tool Dia, of Well Excavation <br /> f Domestic/private ✓ Drilled Dia. of Well Casing _ r <br /> � Domestic/public <br /> Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other .. _ Rotary Type of Grout LPrvJ Q <br /> Other _ Other Information `k <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> k <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 wwell and notifylthemlbeforesh the puttingatheowellninocal use.HeThehriet e <br /> above <br /> WELL DRILLERS REPORT of the <br /> information is true to the best of my knowledge and belief. <br /> k SIGNED TITLE <br /> �F�ORDERRTMENT <br /> REVERSE SIDE <br /> USE ONLY <br /> PHASE I DATE 6-3o-7 <br /> APPLICATION ACCEPTED BY <br /> F ADDITIONAL COMMENTS: pHASE III FINAL INSPECTION <br /> PPOUTIIN <br /> I GROUT INSPECTION DATE �S _7 <br /> INSPECTION BY DATE .-3U'7 INSPECTION BY .r.....L-- <br /> CALL FOR A SPECTION PRIOR TO GROUTING AND FINAL INS ION. 7/72 1M C, <br /> E H 1426 <br />