Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> For. OFFICL•' USF.: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � <br /> s <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 13 nD,.r CENSUS TRACT <br /> Owner's Name / !�C� &J �-� 1. Phone3C9- Cp 3 T 7 <br /> Address City <br /> Contractor's Nam License 03Z�_'Phone� Y7 <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN /_/ RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR J / PUMP REPLACEMENT /7 <br /> Other / / T <br /> DISTANCE TO NEARLST: SEPTIC TAN KI6 (:!) SEWER LINES PIT PRIVY <br /> SE14AGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF LL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> ��__ omestic/private Drilled Dia. of Well Casing 2 <br /> Domestic/public Driven Gauge of Casing /VL- ;— <br /> _,.f!f_Irrigation Gravel Pack Ilppth of Grout Seal k- t�> <br /> Other Rotary Type of Grout I< <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'ZEPAIR: f / State Work Done - �s <br /> �IDRCTRUCTION 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 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 /> FOR DEPARTMENT USE ONLY <br /> PHASE I �c C <br /> APPLICATION ACCEPTED BY �,/�-'�/e�/ DATE 7$ <br /> ADDITIONAL COMNEi NTS: <br /> PHASE II GROUT SPECTION PHAS III/FINAL INSPECTION <br /> INSPECTION BYATF " 7 L INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. J% <br /> E H 1426 _ 5 M lm <br />