Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FQR OFFICE USE: 1601 E. Hazelton Ave. ,' Stockton, Calif. <br /> 1: Telephone: (209) 466-6781 <br /> It APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � � <br /> ii I <br /> i THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued . <br />' <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 <br /> uJoaquin Local Health District, <br /> JOB ADDRESS/LOCATION' � � I <br /> CENSUS TRACT <br /> Owner's Name / "/ 7, � `1�`J ' �—_• <br /> 1: <br /> Address .3Ph-one�` . <br /> - City <br /> Contractor's Name Li <br /> -• cense # Gj z, Phone <br /> R <br /> TYPE OF WORK (Check) : NEW WELL /_7 DEEPEN /_/ RECONDITION /7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT / <br /> OtherL/ / <br /> j� <br /> DISTANCE TO NEAREST: SEPTIC :_TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> q� <br /> I INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS W <br /> �. Industrial ,l Cable Tool Dia, of Well Excavation <br /> ui Domestic/private 1 Drilled Dia-. of Well Casing <br /> ph Domestic/public I Driven Gauge of Casing <br /> Ali Irrigation Gravel Pack Depth of Grout Seal <br /> Other <br /> Rotary Type of Grout <br /> Other Other Information <br /> ilk <br /> PUMP INSTALLATION'. Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /W State Work Done P4 <br /> PUMP. REPAIR: /% State Work Done <br /> ` 4 <br /> ,REST-RUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply withiall 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 /> info' ation is true to the best of my knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT LAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDI'ThONAL COMMENTS:ill j <br /> PHASE II GROUT INSPECTION PHASE I I F NAL INSPECTION <br /> INSPECTION BY HATE INSPECTION BY DATE <br /> C ,LL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> ilk) 702 IM <br />