Laserfiche WebLink
SAN JOAQUIN LOCAL HEEALTH DISTRICT <br />' FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone.:, (209) - 466-.-6781 <br /> PLICATION 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- herebyimade•e.to the.- San JoaquinlLocal 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•iNo;,,1862'-and?the-Rulesi�and .Regulations of=`the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION AIAUS' <br /> TRACT `' <br /> Owner!s Name }.. 11 . . , ::c.- • „ 4 Phone A <br /> 3 <br /> Address 40 City' <br /> Contractor's NameU License # Phoned{ <br /> TYPE OF WORK (Check) : NEW WELL I I DEEPEN '/—/ RECONDITION /_7 DESTRUCTION /_ <br /> PUMP INSTALLATION/ / PUMP REPAIR.,K PUMP REPLACEMENT /? <br /> Other <br /> . 9 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> 1 <br /> i f <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 6` 1 <br /> Industrial. Cable Tool Dia. of Well Excavation C> <br /> Domestic/private Drilled Dia. of Well Casing " I <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rdtary. Type of Grout <br /> Other Other Information A <br /> i <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /.°/ State Work Done <br /> PUMP REPAIR:_ Stag Work .Done ..� �' - - • •: <br /> ,DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> T 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 w�__ _ TITLE ' <br /> ' (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PRASE I <br /> APPLICATION ACCEPTED BY .. DATE <br /> ADDITIONAL COMME1gTS. <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 4/72 1M <br /> 1 <br />