Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT W _. <br /> FOR OFFICE USE: 1601 E. Hazel,tori Ave'. , Stockton, Calif. <br /> " Telephone: (209) 466--6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z -7 5 3 <br /> THIS PERMIT EXPIRES 1 YEAR FRO14 DATE 'ISSUED Date Issued <br /> (Complete In'Triplicate) <br /> Application is...hereby mader.to -the San Joaquin Local. Health District for a permit to construct <br /> anal/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 Joaquin Local Health District. <br /> 4 JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner.'s Name Z/.,, <br /> -7k Phone ' 9.? <br /> Address <br /> City <br /> Contractor's NameAa-vz _,o!LaLicense �� Phone <br /> X.f'S 7// <br /> TYPE OF WORK (Check) : NEW WELL /_7 DEEPEN '/_/ RECONDITION /_7 DESTRUCTION /7 <br /> AL <br /> PUMP INSTLATION PUMP REPAIR '/—/ PUMP REPLACEMENT <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES 7' .VJ PTT PRIVY T <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> e� I <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 f <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. 1 <br /> PUMP REPLACEMENT: / State Work Done <br /> PUMP REPAIR: /- / State' Work Done <br /> ,DESTRUCTION 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 RPORT of the well, and notify them before putting, the well in use. The above <br /> information s rue to--the best of my knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY l DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS ' I, I/FINAL I SPECTION <br /> INSPECTION BY DATE _ INSPECTION BY ATE -5 - � <br /> CALL FOR A GROUT INSPECTION PRIOR TO GR ._� '7 <br /> OUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />