Laserfiche WebLink
- SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> k0£.-OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> ' Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �734 <br /> THIS PERMIT. IEXPIRES I. YEAR FROM. DATE ISSUED Date Issued Z=,2-6-.7,-? <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 Sant Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the Sant Joaquin Local Health District. <br /> JOB ADDRESS./LOCATION 7 r <br /> CENSUS TRACT <br /> Owner's Name 10 Phone -ZUS <br /> Address.2Z City i <br /> Contractor's Name Licenses Pho <br /> i <br /> TYPE OF WORK (Check) : NEW WELL ff DEEPEN / / RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION /—/ PUMP REPAIR / / PUMP REPLACEMENT /- <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 SPECIFICATIONSI <br /> Industrial Cable Tool. Dia. of Well Excavation <br /> of Domestic/private Drilled Dia. { <br /> 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 /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. r � <br /> PUMP REPLACEMENT: / / State Work Done <br /> -PUMP"zEPAIR: _ /�). State Work Done <br /> .DFgTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure a <br /> 04P A�el•f ¢ <br /> !� <br /> I hereby agree to comply with all laws and regulations of he San Joaquin Local Health District r <br /> and the State of California pertaining to or regulating wel.l ''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 /> (DRAW PLOT PLAN ON REVERSE SIDE ; <br /> PHASE i FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: ^' - <br /> PIIAS )EI GRQVT INSPECTION_ PHAS I/FI AL INSPEC IO <br /> INSPECTION BY DATE 1 Z INSPECTION BY DATE / <br /> CALL FOR A GROUT INS CTION PRIOR TK GROUTING AND FINAL INSPECTION. <br />