Laserfiche WebLink
s <br /> 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, ��7-/�Sk/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> 'Application is hereby- made td� 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 drdinanceV_0 1862 and# the Rules and Regulations of the San Joaquin Local Health District. <br /> ..: <br /> JOB ADDRESS/LOCATION / ./ y .ry..... _ CENSUS TRACT <br /> Phone <br /> Owner's Name <br /> Address City ev <br /> r <br /> Contractor's Name Se ' License # Phone <br /> TYPE OF WORK (Check) : NEW WELL /7 DEEPEN /_7 RECONDITION /7 DESTRUCTION <br /> PUMP INST LATION / / PUMP REPAIR / PUMP REPLACEMENT /? <br /> l Other / <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 a <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> r <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> } - Others Rotary Type of Grout <br /> i ^' — OtherOther Information <br /> I PUMP INSTALLATION. Contractor H.P. <br /> �n Type of Pump <br /> pump. PLACEMENT <br /> State Work Done <br /> PUMP REPAIR. /i!' State Work Done_SP <br /> 1 .10: Depth �G _ <br /> ESTRUCTION OF WELL: Well Diameter Approximate <br /> r.� Describe Material and Procedure <br /> '.Yjereby 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 /> �J TLE Y � <br /> SIGNED` RAW PLOT LAN ON REVERSE SI E <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE / <br /> APPLICATION ACCEPTED BY <br /> fi ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPE ON PHASE III/FINAL INSPECTION <br /> f,INSPECTION BY <br /> DATE INSPECTION BY DATE <br /> ,' CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> 7/72 1M <br /> ',H <br /> 1426 <br />