Laserfiche WebLink
'ek <br /> _ -1: SAN JOAQUIN LOCAL HEALTH DISTRICT 8 <br /> CEEU5:^ 1601 E. Hazelton Ave. , Stockton, Calif. <br /> r Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 3 �J <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 leo. 1862 and the Rules and Regulations of the San Jo uin Local Health District. <br /> �t G�'XQx� �' L n cut" c /2 27(0 �C c <br /> .TOB ADDRESS/LOCATION .S �. � �P CENSCS TRACT <br /> Owner's Name Phone <br /> AddressCity <br /> Contractor Name License PhonemeLG <br /> TYPE OF WORK (Check) : NEW wWELL DEEPEN '/ / RECONDITION /�/ DESTRUCTION /-7 Y <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /- <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK G SEWER LINES PIT PRIVY <br /> SEWAGE D�S,EOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER k <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �1 <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge-of Casing 4 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> y Other _ Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMLNT: /-7- State Work Done <br /> PUMP 'ZEPAIR: _ /% State Work Done <br /> .DF.qTRUCTION 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 thein 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 Z <br /> APPLICATION ACCEPTED .BYp _ .---- DATE <br /> ADDITIONAL COMMENTS: c <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY • DATE INSPECTION BY � DATE - <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 5/731M <br />