Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.� -/29!� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION s /�� oil'//U /( G - -_----- — CENSUS TRACT <br /> Owner's Name /? /'2 Phone ?jl <br /> Address �0� 6�!/L ( 7X 1;241 ---- — _ City <br /> Contractor's Name License 4 �Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION / J PUMP REPAIR / / 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 w. <br /> Industrial Cable Tool Dia. of. Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing ' <br /> Domestic/public Driven Gauge of Casing Z <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 /> PUMP REPLACEMENT: / / State Work Done <br />' PUMP REPAIR: / / State 'Work Done <br /> 4 ,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 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 TITLE 0 / 1 !/ _ <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> . . FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE -- <br /> . ADDITIONAL COMMENTS: T <br /> r. PHA E I GROUT ItSPECTI2PHASE III FINAL INSPECTION <br /> INSPECTION B ATE -INSPECTION BY DATE <br /> CALL FOR A GROUT NSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> r <br /> 7/72 1M <br /> E H 1426 <br />