Laserfiche WebLink
ya) SAN JOAQUIN LOCAL HEALTH DISTRICT ���•-p �j�J E <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. f <br /> Telephone: (M) 466--6782 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ! 1 <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued /a <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 Rule5 and -Regulations of the San Joaquin, Local Health District. <br /> W. <br /> JOB ADDRESS/LOCATION /r . AlCENSUS TRACT <br /> Owner t s Name / a. _ ` Phone <br /> Address fwd 6) Mj City <br /> Contractor's Name ,.tnr. License # Phone <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / -PUMP REPAIR / / PUMP REPLACEMENT J, <br /> Other /_7 <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 Casings <br /> Domes tic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> S <br /> PUMP INSTALLATION: Contractor 4_4_,' ,, <br /> _70— <br /> Type of Pump H.P. "'� <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> PESTRUCTION_ 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 t <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 �r� TITLElom <br /> (DRAW PLOT PLAN ON REVERSE SIDE` ._ <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> i PHASE II GROUT INSPECTION PHASE III F NAL INSPECTION <br /> 1 INSPECTION BY DATE INSPECTTION BY DATE 19 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />