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. a_5?7/)0 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued .6-3,9-7,4 <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 CENSUS TRACT <br /> Owner's Name Phone .�` ���/—� <br /> Address � .� �' -- City <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check): NEW WELL / DEEPEN /_/ RECONDITION /_7 DESTRUCTION /_ <br /> PUMP INSf LATION PUMP REPAIR / / PUMP REPLACEMENT /_7 <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 Casing <br /> Domestic/public Driven Gauge of Casing <br /> .- Irrigation Grave]. Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> ' me zl" <br /> UMP INSTALLATION. Contractor � <br /> A2 <br /> Type of Pump " H.P. <br /> PUMP REPLACEMENT: /_7 State Work Done <br /> t <br /> r - <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 V ----- - .TITLE <br /> t -"(DRAW PLOT PLAN ON REVERSE SIDE <br /> k � FOR DEPARTMENT USE ONLY— - <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE � 17� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE, II INAL INSPECTI <br /> INSPECTION BY DATE.T - INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND 'FINAL INSPECTION. <br /> 7/72 1M <br /> E H 1426 <br />