Laserfiche WebLink
JOAQUIN LOCAL HEALTH DISTRICT <br /> PAOERO�E�CE USE: yjl_"16011�. Hazelton Ave. , Stockton, Calif. <br /> Telephone.: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 r <br /> i <br /> THIS PEMT EXPIRE=S 1 YEAR FROM DATE ISSUED Date Issued <br /> HI �Y <br /> (Co*lete In Triplicate) <br /> Application is, hereby .made do the Safi-Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is" made in compliancetwith San Joaquin <br /> County Ordinance No.' 1862 and the .Riles and Regulations of the San <br /> �I+Joa •uonLocal Health District.. <br /> CENSUS TRAeT <br /> JOB ADDRESS/LOCATION ... -- <br /> Omer's Nam Phon -7 <br /> Address ' City <br /> Z. Phone '�3 <br /> Con•traetoxe s Name License _-•�� <br /> t <br /> TYPE .Oi 'WORK (Check): NEW WELL L�DEF;EN /� RECONDITION /� DESTRUCTION !T 4 <br /> 3Pw wsTALLATION /- PUMP REPAIR 1 /f PUMP REPLACE��c -7 � <br /> other /% <br /> { � m <br /> DISTMCE TO NEAREST: SEPTIC TANK SEM LINES PIT PRIVY <br /> ` SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WILL CONSTRUCTION SPECIFICATIONS � <br /> Industrial a Tool Dia. of Well Excavation ; <br /> Domestic/private Drilled Dia. of Well Casing �- <br /> Dome is/public Driven Gauge of Casing 9w== <br /> rrigatiou Gravel Pack Depth of Grout Seal. � <br /> Other ---- Rotary Type of Grout i <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. 1 <br /> PUMP .REPLACE-WNT: / J State Work Done <br /> PUMP R£FAIR. . / ,ate Work <br /> f,DESTRUCTION 4F 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 Californiatpertaining 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 /> IWELL DRILLERS REPORT of thefwell and notify them before putting the well in use. The above <br /> information is true to the beat of my knowledge and belief. <br /> SIGNED i"l~ TITLE , <br /> (DRAW PLOT PLAN ON REVERSE sIDB <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> ?PLICATION-ACCEPTED BY � ��► _ _ DATE � <br /> _,DDITIONAL COM4ENTS �' <br /> PHASE II, GROUT' INSPECTION P III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE -- <br /> CALL FAR A GRL)UT_INSpZCTIM .PRIOR TO-GROUTING AND FINAL INSPECTION. <br /> B H 1426 --- 7/72 1M <br /> I <br />