Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 4666781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.,7 3 4-) <br /> 73 -7os-i" <br /> THIS PERMIT EXTIRES 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/tem-r1`OR57 q <br /> r-- r CENSUS TRACT <br /> Owner's Name /� Phone <br /> Address - -- ll// • <br /> L//_� � T� ��; j City <br /> Contractor's Name / ,SLicense Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION /_7 DESTRUCTION /_7PUMP INS ALLATION X PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK. SEWER LINES PIT PRIVYAJAkC <br /> SEWAGE DISPOSAL FIELD CX&&P96L/SEEPAGE PIT,rp�d-- OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation L <br /> Domestic/private Drilled Dia. of Well Casing p� <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal / <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor 4, . <br /> Type of Pump H.P. S" <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR:., / / State Work Done <br /> .pESTRUCTION 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 <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> informative u to he est of my knowledge and belief. <br /> SIGNED TITLE <br /> {DRAW PLOT PLAN ON ,REVERSE SID — _FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION AC EPT D BY DATE <br /> ADDITIONAL CO NT -- <br /> P SE INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE - INSPECTION BY / DATE - <br /> CALL FOR A G O CTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 `-' 7/7 lM <br />