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 No. :,--[ ) G.jj <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Lj-j 3 <br /> (Complete In Triplicate) <br /> Application is here y 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 /> JOB ADDRESS/LOCATION <br /> //J1Ll CENSUS TRACT S q 6 <br /> Owner's Name 1r On � Phone <br /> Address5�, <br /> ' City ®� <br /> Contractor's Name ;L,(� A License �E� !C&hone <br /> TYPE OF WORK (Check): NEW WELL JX DEEPEN /_-7 RECONDITION /_-7 DESTRUCTION /- <br /> PUMP INST LATION / / PUMP REPAIR /—/ PUMP REPLACEMENT /-7 <br /> Other / / <br /> DISTA5Cj TO NEAREST: SEPTIC TANK SEWER L PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT -,t " OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> IndustrialCable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing —TTo <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / J State Work Done <br /> PUMP REPAIR: J / 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 no ify them before putting the well in use. The above <br /> information isto the best of m owledge and belief. <br /> tr <br /> SIGNED TITLE xw , <br /> DRAW PLOT P ON REVERSE SID <br /> FOR DORTMMIT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �,�y�� u DATE y--.� " <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE --z- <br /> r-CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTIO . <br /> E H 1426 7/72 1M <br />