Laserfiche WebLink
br(N JOAQUIN LOCAL HEALTH DISTRICT <br /> FX. OFFICE USIA, 1601 E. Hazelton Ave. , Stockton, Calif. <br /> _ Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. _5i <br /> i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issuedri-4-�Z <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 Joaqui <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION cS �j ✓I/I 4Z t- qy CENSUS TRACT <br /> Owner's Name ,5U4J E N Phone Sf�y- 737J� <br /> Address City zs<f/4.(f).cj <br /> Contractor's Name �Q � j License 11 j2pJnPhone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / RECONDITION /_/ DESTRUCTION /-7 <br /> AL <br /> PUMP INSTLATION /WPUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TAivK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER (1 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation V <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 fi <br /> Other Other Information <br /> PU:-T INSTALLATION: Contractor <br /> Type of Pump 151 H.P. ° _ <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> DFgTRUCTION 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 /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District i <br /> Tvi,LL 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 /> (D LOT PLAN ON REVERSE SIDE) <br /> F DEPARTMENT USE ONLY <br /> P.iASE I <br /> APPLICATION ACCEPTED BY & DATE <br /> ADDITIONAL COMPIENTS: <br /> PILA IN ECT 9I INAL INSPECTIW <br /> INSPECTION BY DATEINSP TION B VIA, DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br />