Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit1 No. 7Z-zG !a <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r Date Issued 9='Z 7 <br /> (Complete In Triplicate) <br /> Application is hereb 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 Sart Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> { <br /> Owner's Name Phone <br /> Address d1 <br /> City <br /> Contractor's Name }; r <br /> License # le___S7�_ Phone e <br /> TYPE OF WORK (Check) : NEW WELL J / DEEPEN /? RECONDITION 1-7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR /V/ PUMP REPLACEMENT /_7 <br /> -Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 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 /> 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 ' <br /> Type of Pump H.P. <br /> PUPPP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: <br /> State Work Dane <br /> ESTRUCTION 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 /> SIGNED 1 .�,_.ef.6,Kix . ���._� TITLE ` r �y <br /> V (DRAW PLOT SON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> S <br /> PHASE II GROUT INSP CTION PHASE II F AL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> Y <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. '..; x � <br /> E H 1426 a 7/72 1M <br />