Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> '0F. OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �Y� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDDate 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 Ordi:nanc No. 1.862 and the Rul s and Regulations of the ?V1;W <br /> uin. Local. Herlth Dispri.ct.JDB 0AFIDRE L0 ION/ ! , W c�1 uS TRACT <br /> Owner's Name �/' le- p nes <br /> Address PCity �1n"A?e-v <br /> 1 <br /> Contractor's Name License #awwPhone - <br /> TYPE OF WORK (Check) : NEW WELL <br /> ,,K DEEPEN RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION X,_PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK I' SEWER LINES PIT PRIVY <br /> SEWAGE DISPOS FIELD CESSPOOL/SEEPAGE PIT OTHER 0 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS � <br /> Industrial Cable Tool Dia, of Well Excavation / Tq� <br /> I Domestic/private Drilled Dia. of Well Casing G <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal �i <br /> Other Rotary Type of Grout 01 <br /> Other Other Information AOM Alwelftv <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.PJ4. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP UPAIR: #/ / State Work Done <br /> DFsTRUCTION 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 DR PORT of the well and notify them before putting the well in use. The above <br /> inform ion is ru t 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 <br /> APPLICATION ACCEPTED BY / ' DATE "�` y <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE r-.'_ 1- ?V INSPECTION BY DATE •7 <br /> t <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. Wft <br /> E H 1426 5/731M <br />