Laserfiche WebLink
` — SAN JOAQUIN IOCAL"HEALTH DISTRICT <br /> FOR MICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ?2-1: &/ <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued 11 2.2-9i <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 Na. 1862 and t RulesRegu tions of the San Joaquin Local Health District. <br /> JZO <br /> JOB ADDRESS/LOCATIONL CENSUS TRACT <br /> Owner's Name2 Phone <br /> /� <br /> Address C' c City <br /> Contractor's Name License # Phone .Z - M1 <br /> _ 1 <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN /-7 RECONDITION /_ STRUCTION /7 <br /> PUMP INSTALLATION / / P PAIR /% PU2 PLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES P PRIVY <br /> SEWAGE DISPOSAL FIELD CESS 0 V\U AGE PIT OTHER �r <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> — Industrial Cable Tool Dia. We711 Excavation <br /> Domestic/private Drilled ia, of Well Casing <br /> Domestic/public Driven auge of Casing <br /> Irrigation Gravel Pack pth f Grout Seal <br /> — - Other Rotary Type of Grout <br /> _ Other Ot r Information <br /> f <br /> PUMP INSTALLATION: Contractor ' <br /> Type of Pump H.P. (10 <br /> PUMP REPLACEMENT: / / St t Wo�, ne� <br /> PUMP REPAIR: <br /> /-7 St ov Do <br /> ESTRUCTION OF WELL: Well Diame Approximate Depth <br /> Describe Mate ia1 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 <br /> � TITLE b <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR VEEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> COMMENT : <br /> PHAS3tjj ROUT INSPECTION PHASE FIIJFFINAL INSPECTION . <br /> INSPECTION BY ._ DATE INSPECTION BY DATE <br /> CALL FOR A/ UT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION <br /> E H 1426 7/72 1M <br />