Laserfiche WebLink
1 SAN JOAQUIN LOCAL IiEALTH 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. S <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued L2dIV <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 W51) CENSUS TRACT �7 <br /> Owner's Name ASEI-TT7Phone <br /> AddressAme City T � <br /> Contractor's Name LOR DER- License # Phone <br /> TYPE OF WORK (Check) : NEW WELL _Gl' DEEPEN/_/ RECONDITION /_� DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY S <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> v <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation � � Q <br /> Domestic/private Drilled Dia, of Well Casing X7 <br /> Domestic/public Driven Gauge of Casing o1 <br /> Irrigation Gravel Pack Depth of Grout Seal Sp <br /> Other Rotary Type of Grout _ Cn <br /> Other Other Information ._. <br /> 1 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <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 true to the best of my knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE -� -� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPEC PHASE III/FINAL INSPECTION <br /> INSPECTION BY fel DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION OR TO GROUTING AND FINAL INSPWION. <br /> E H 1426 4/72 IM <br />