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 <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 San Joaquin' <br /> County Ordinance No. 1862- and the Rules and Regulations of the San Joaquin Local Health District. -, <br /> JOB ADDRESS/LOCATION Cf-eI 9L1W W CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address <br /> City <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN / / RECONDITION /7 DESTRUCTION /-7 <br /> PUMP INSTALLATION §Zr 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 /> I +, <br /> INTENDED USE I Ik"-TYPE OF W <br /> ��� CONSTRUCTION SPECIFICATIONS <br /> Industrial i Cable Tool Dia, of Well Excavation <br /> Domestic/private it Drilled Dia, ofWellCasing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation " Gravel Pack}_ `. 'Depth of- Grout Seal <br /> .-Other Rotary_ F Type of Grout �.., <br /> i! Other Other Information - <br /> PUMPIINSTALLATIONF Ctiritractor <br /> Type of Pump H.P. r <br /> PUMP REPLACEMENT: <br /> State Work Done r ? <br /> PUMP REPAIR: / % State Work Done \ <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure I <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 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 <br /> TITLE <br /> W PLOT PLAN ON REVERSE SIDE <br /> PHASE I I� <br /> FOR DEPARTMENT USE ONLY fi <br /> 'PLICATION ACCEPTED BY DATE 1,2- -f -7.3k'. <br /> WDITIONAL COMMENTS: <br /> -- . <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BYDATE <br /> CALL ,FOR,A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 <br /> i� _ 44�5-2 1M <br />