Laserfiche WebLink
_ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOf..OFI�ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> a <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7K-1SS� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued zL-L.5-2E, <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. 8 d the Rules and Regulations of the San Joaquin Local Health District. 1 <br /> JOB ADDRESS/LOCATION CENSUS TRACT, <br /> Owner's Name ,fl __ Phone <br /> Address City <br /> Contractor's Name License # Phone " <br /> TYPE OF WORK (Check)_: NEW WELL/ I 'DEE PEN '/�7/ RECONDITION /_/ DESTRUCTION / <br /> AL <br /> PUMP INSTLATION � PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other J / , <br /> DISTANCE TO NEAREST: SEPTIC TANK 1,1a SEWER LINES /p C1 PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well. Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> F <br /> Domestic/public Driven Gauge of Casing it <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> i <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. �! <br /> h <br /> PUMP REPLACEMENT: 17/e State Work Done <br /> PUMP -tEPAIR: / / State Wozk Done <br /> ,DF9TRUCTION 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 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 /> N <br /> Y SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED .BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE ;I /FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> ' S/731M <br />