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. 6 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued <br /> C' (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 SUS TRACT <br /> Owner's Name. ' Phone 's-6 <br /> Address .� / -� Lo5k_ r k <br /> .. - .,. -. -• °� ,_..._�..�:__... city -- <br /> Contractor's Name ) License #11_2Z2_? Phone 3 <br /> I& <br /> TYPE OF WORK (Check): NEW WELL/ / DEEPEN '/—/ RECONDITION /_7 DESTRUCTION. /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR '�- ' PUIP_REPLACEMENT /_j <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 x <br /> Industrial Cable Tool Dia. of Well Excavation <br /> >e,_ Domestic/private Drilled Dia. of Well-Casing <br /> Domestic/public Driven Gauge of Casing <br /> = Ir.r .-gation - - Gravel-'Pac'k Depth--6f"Grout Seal <br /> Other Rotary Type of Grout N <br /> Other Other Information ' <br /> PUMP INSTALLATION: Contractor - ' <br /> Type of Pump H.P. <br /> _ h <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 REPORT of the well and notify them before putting the well in use. The above <br /> information is tr a to the best of my knowledge and belief. b, <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE %11/7 Z1 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ,s/ .,� DATE _/�'�� <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 IM <br />