Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> For—OFFICE 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 Issued ,<-..zs 7� <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/oz 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 District. <br /> JOB ADDRESS/LOCATION S9-0- n1 V f,,. CENSUS TRACT <br /> Owner r s Name 5 e.r r Se r D Phone <br /> Address e-• City ' •� �C n _ <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check) : NEW WELL / % DEEPEN '/ RECONDITIONS/% DESTRUCTION / <br /> PUMP I INST—ALLATION / PUMP REPAIR / J PUMP REPLACEMENPIf <br /> Other — <br /> j <br /> IYISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> 1 <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 /> 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. <br /> PUNP REPLACEMENT: / J State Work Done <br /> 3 — <br /> PUMP UPAIR: / / State Work Done <br /> Olt <br /> ;DF-,TRUCTION OF WELL: Well Diameter Cleo Approximate Depth tSd <br /> Describe Material and Procedure <br /> ti <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'of therwell. 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 /> t PHASE I / <br /> APPLICATION ACCEPTED BY �6DATE f0 <br />:E ADDITIONAL COMMENTS: 3 <br /> PHASE II GROUT: I PECTIONPHAS I/F AL INSPECTION <br /> ` INSPECTION BY DATE INSPECTION BY D�W <br />,i CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPEC N. <br /> r# F u ILM K/7 ilm <br />