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 PU14' PERMIT Permit No 40 <br /> THIS PERMIT EXPIRES l YEAR FROM DATE' ISSUED Date Issued : y/v-7 <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 Focal Health District. <br /> JOB ADDRESS/LOCATION ZIV ,� CENSUS TRACT <br /> Owner's Name -� <br /> + - Phone GIZ - <br /> + Address ". <br /> _ City { ..., <br /> Contractor's Name _ —r License <br /> AW_ Phone <br /> 's TYPE OF WORK (Check).: NEW WELL / DEEPEN /_% RECONDITION / / DESTRUCTION <br /> s PUMP INSTAL TION K PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> f �- <br /> 'DISTANCE TO- NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> s SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> ` INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> ,_,_,P< 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 er- <br /> - - Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump - H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ,,DESTRUCTION00 <br /> OF WELL: Well Diameter did �r 0 /P7414 Approximate De th <br /> k Describe Material and Procedure �f� .A hi,/_-_��/q <br /> F 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 /> I after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> t WELL DRILLERS REPORyAf 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. <br /> SIGNED TITLE <br /> (DRA LOT PLAN ON REVERSE SIDE <br /> FO IXPARTMENT,,USE ONLY <br /> ! PHASE I {. <br /> '-APPLICATION ACCEPPI`M IRY Q / DATE <br /> , ADDITIONAL COMMENTS: <br /> �• P II GROUT INSPECTION <br /> INSPECTIO <br /> f INSPECTION BY DATE INSPECTION B_Y DATE <br /> 1, <br /> CALL FOR A GR T INSPECTION PRIOR TO GROUTING AND FINAL INSPECT ON. . C <br /> �E H 1426 - ' . 7/72 1a. <br />