Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE; 1601 E. Hazelton Ave. , Stockton, Calif. <br /> r Telephone.: (209) .466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. U-1 6 3 <br /> THIS PERMIT- EXPIRES 1 YEAR. FROM. DATE ISSUED Date Issued 8.17• I <br /> t lol 7_7L�.,. —"T iP0'^7.- (Complete In Triplicate) DI' 013—.Z.,0,70. <br /> .Application..is..hereby:,made! to ,thea-San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made incompliance with .San Joaquin <br /> County .Ordinance No.., 1862 .and-.the- Rul and Regulations%of the San Joaquin Local Health District, <br /> JOB ADDRESS/LOCATION 3 � CENSUS TRACT <br /> Zj � <br /> Owner.'s Name.'i Phone6 <br /> Address 625 ,/ .�uvu�� V itY <br /> Contractor's Name cense i7/�66-Phone ' <br /> �z7 <br /> F <br /> 'TYPE OF WORK (Check) : NEW WELL DEEPEN/ / RECONDITION /7 DESTRUCTION /`7 <br /> PUMP INST LATION / / PUI ' REPAIR / / PUMP REPLACEMENT <br /> Other <br /> 'DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY Q� <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> t <br /> 4 INTENDED USE TYPE- OF-WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial P _ Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> : Other Other Information <br /> P PUMP INSTALLATION:, Contractor <br /> P e Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Donee ` <br /> PUMP. REPAIR: / / State Work Dane r <br /> ESTRUCTION 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 bel4ef. <br /> ' SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE I�- <br /> ,ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE ' INSPECTION BY gaf��__ — - DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E'H 1426. 4/72 1M <br /> r - <br />