Laserfiche WebLink
O SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephones (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> f <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED, Date Issued -�3 <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 /> .TOB ADDRESS/LOCATION � � at �, L�lr,� � � _ <br /> CENSUS TRACT <br /> k <br /> Owner's Name �. �v) �C - --_—_- Phone <br /> Address CityS[J, .l�j�� <br /> Contractor's Name - License #0�Phone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN /7 RECONDITION /-7 DESTRUCTION <br /> PUMP INSTALLATION /-CA-7PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: 'SEPTIC TANK SEWER LINES PIT PRIVY p <br /> SEWAGE DISPOSAL FIELD o CESSPOOL/SEEPAGE PIT OTHER b <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS K <br /> Industrial Cable .Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia, of, Well Casing <br /> Domestic/public Driven Gauge of .Casing <br /> _ . <br /> Irrigation Gravel-Pack Depth of Grout Seal <br /> Other Rotaki- Type of Grout <br /> Other . Other Information <br /> PUMP INSTALLATION: Contractor <br /> — <br /> �._� Type of Pump.. . - H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR:-- T --/--/--S`tate Work Dobe-- , <br /> ,RESTRUCTION OF WELL: Well Diameter r Approximate Depth <br /> Describe Material and Procedure <br /> ' L <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._-.v r .. _ <br /> SIGNED2t TITLE gt%."-�X �a� � �; <br /> lop, (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I , <br /> APPLICATION ACCEPTED BY C. DATE <br /> ADDITIONAL COMMENTS: 01 <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY 4k Z9 DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M , C,�o j <br />