Laserfiche WebLink
�O F <br /> FOR OFFICE USE: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 16{]2 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permi�� <br /> it No. 73� <br /> i <br /> THIS, PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In Triplicate) Date <br /> l�I�suedZ 31� 73 <br /> Application is hereby made to the San Joaquin Local Health District for a permitlto construct <br /> and/or install the work herein described. This application is made in compliance with San Jos <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local'�Health District. <br /> e Ir t <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> Owner's Name <br /> Phoney <br /> Address <br /> City� _ ,` �` <br /> Contractor's Name ,yt <br /> . L cense # phonef y <br /> a � r <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION /-7 DESTRUCTION 0 <br /> f PUMP INSTALLATION L/ PUMP REPAIR /—/ PUMP REPLACEMEN—T <br /> Other Z77 -- <br /> j DISTANCE TO NEAREST: SEPTIC TANKIM <br /> SEWAGE DISPOSAL FIELDER LINES PIT PRIVY . <br /> CESS OOP L/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL <br /> Industrial CONSTRUCTION SPECIFICATiIONS <br /> Domestic Cable Tool Dia, of Well Excavation <br /> /private Drilled Dia. of Well Casing <br /> Domestic/public Driven M <br /> Irrigation Gauge of Casing <br /> Gravel Pack. Depth of Grout Seal <br /> ii <br /> Other RotaryIM <br /> Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: I� <br /> Contractor ; <br /> Type of Pump <br /> H.P. ! <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR° / / State Work Done A <br />,RESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <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. Y <br /> after completion of my work on a new well, I will furnish the San Joaquin LoWithin ;FIFTEENcal Health S <br /> TEEEEN N DAYS <br /> t a <br /> WELL DRILLERS REPORT of the well and notify them before putting the we <br /> information is true. to the best of my knowledge and belief. ll fn use. The above <br /> is <br /> SIGNED i <br /> ( <br /> TITLE J�DRAW PLOT PLAN ON REVERSE SIDE) I� <br /> PHASE I FOR DEPARTMENT USE ONLY C <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE �` 2, <br /> PHASE II GROUT INSPECTION / a <br /> INSPECTION BY DATE _ PRAS INAL INSPECTION <br /> INSPECTION BY _ DATE S: J 73 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 <br /> 7/72 1M CO <br />