Laserfiche WebLink
-. � �.. <br /> ' SAN JOAQLIN LOCAL HEALTH DISTRICT <br /> FFICE USE:::- 1601 E. Hazelton Ave. , Stockton, Calif. <br /> _ Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> { � t <br /> -THIS PERMIT EXPIRES .I. YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Appl <br /> an ication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> for- install the work herein described. • This application is made in compliance with San Jo <br /> aqui,Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB AD <br /> DRESS, C r <br /> W_ �,e�z_ CENSUS TRACT <br /> Owner's Name Phone <br /> Address <br /> jjCity ' ' <br /> Contractor's Name I' <br /> / License / Phone _: <br /> TYPE OF WORK (Check) : NEW WELL/ // DEEPEN '/ / RECONDITION /% DESTRUCTION /_7 <br /> PUMP INSTALLATION / / LUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other /_7 <br /> -- <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 <br /> Domestic/private '_Drilled Dia. of Well Casing <br /> i Domestic/public Driven Gauge of Casing <br /> Irrigation XGravel Pack Depth of Grout Seal s1 <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 /> PUMP�AEPAIR:. - -'-- <br /> /�/�.=-5ta�e-�do�r�c�-Donee. -��=...�=-=�-•---.�---��. <br /> .DFI,TRUCTION 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 oE .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 />` (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE; I <br /> APPLICATION, ACCE}2TED .BY- DATE/ l <br />' ADDITIONAL,C. %1MENTS: .� <br /> PTIASE :IT GR UT INSPE I <br /> PHASE III E� AL INSPECTION <br /> INSPECTION BY DATE INSPECTION $Y ATE <br /> _CALL FOR-0AtGROUT_INSPECTION ,PRIOR TO GROUTING AND FINAL INSPECTION. _ <br /> E H 1426 <br /> C�/71�u '� <br />