Laserfiche WebLink
IX <br /> SAN JOAQUIN LOCAL"M-ALTH DISTRICT <br /> OT'..01 F ICE' USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> ! APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT- EXPIRES 1 YEAR FROM- DATE ISSUED Date Issie!Li,2 ap-7d <br /> (Complete In Triplicate) +r► � <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 Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health Disrrict. <br /> JOB ADDRESS/LOCATION ��" ! CENSUS TRACT <br /> Owner's Name n d Phone <br /> Address y City ' ' <br /> Contractor's Name . . License hon <br /> � 3 6Ij <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/ / RECONDITION /_/ DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR-/ / PUMP REPLACEMENT /-7 <br /> Other / ! <br /> DISTANCE TO NEAREST: SEPTIC TA14K = SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS R� <br /> Industrial Cable Tool Dia. of Well Excavation <br /> ,VDomestic/private Drilled Dia. of Well Casing 4 <br /> _: __Domestic/public..ri:.. - .D.riven _v __,}�augg-of,:_Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> i Other /Rotary Type of Grout <br /> �--7 Other Other Information <br /> i <br /> ,'PUMP INSTALLATION: Contractor <br /> • K• Type of Pump H.P. <br /> 'UMP REPLACEMENT: / / State Work Done <br /> PUMP 'REPAIR: / / State Work Done <br /> DF5TRUCTION 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 /> s' 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 /> R DEPARTMENT USE ONLY <br /> PILkSE I <br /> '} APPLICATION ACCEPTED -BY DATE <br /> 1 11 4 A� <br /> { ADDITIONAL COMMENTS: <br /> P <br /> 11 OUT INSPECTIO,.x PHAP III-/FINAL INSPECTION <br /> INSPECTION B DATE e INSPECT7� <br /> k; CALL FO UT INSPECTIO PR ROTO GR40UTING ANI FINAL INSPECTION. C)U-tl <br /> E H 14 r6 5/731M . <br />