Laserfiche WebLink
SAN JOAQUItt LOCA7, HEALTH DISTRICT <br /> FOL-OII E USE:: 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (.209) 466--6781 � <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT s Permit No. <br /> THIS. PERMITxEXPIRES 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 :Wade 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 60Ccs CENSUS TRACT � <br /> Owner's Name rs , Phone <br /> Address / �' -c. City <br /> 4 <br /> License '# r-Phone` �' <br /> Contractors Name: ifT � � ..�• -_ _ � f'.�� <br /> TYPE OF WORK (Check) : . NEW WELL / DEEPEN••/!/; RECONDITION / / DESTRUCTION <br /> PUMP INSTALLi4 I0N / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST_ : SEPTIC TANK SEWER:LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OFJ. ELL CONSTRUCTION SPECIFICATIONS <br /> Industrial able Tool Dia, of Well Excavation --- " <br /> Domestic/private - - Drilled s Dia. of Well Casing <br /> D�mestic/public Driven �: Gauge of Casing <br /> Irrigation Gravel Pack; Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> 9 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> 1 <br /> PUMP rtEPAIR: .- /--•/-- State:.Work. Done. _ <br /> ` y <br /> .DFsTRUCTION OF WELL: Well Diameter 1 _ _ ..Approximate Depth _ <br /> Describe Material and Procedure ` <br /> } <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of Cali.for'nia 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 /> [BELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is true to the 'bestiof my knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR.DEPARTMENT_USE ONLY <br /> PHASE I � <br /> APPLICATION ACCEPTED .BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION J <br /> INSPECTION BY DATE INSPECTION BY r. DATE <br /> CALL- FOR A-GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 �71M - <br />