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 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued _fir <br /> (Complete In Triplicate) <br /> Applicat ish reby 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 Na. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �/' CENSUS TRACT S 4 Z <br /> Owner's Name Phone-36 5p- ? <br /> Address (�. S�(S City <br /> Contractor's Name eC-c-� �J�/ License ill6 3 Phone 3`a to <br /> TYPE OF WORK (Check): NEW WELL „ DEEPEN /-7 RECONDITION /-7 DESTRUCTION / <br /> PUMP INSTALLATION / / PUMP REPAIR / j PUMP REPLACEMENT /7 <br /> Other / <br /> DISTANCE TO NEAREST: SEPTIC TANK S SEWER LINES cArg PIT PRIVY /Lj-j&,C <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial X Cable Tool Dia. of Well Excavation / . <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> �X Irrigation Gravel Pack Depth of Grout Seal -- <br /> Other Rotary Type of Grout — <br /> Other Other Information <br /> PUMP INSTALLATION Contractor b---'� <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <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 TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> A <br /> APPLICATION ACCEPTED BY DATE 7— <br /> ADDITIONAL COMMENTS: <br /> PHASE II INS T-Ift PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY - DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />