Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Oil <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z LI "l <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued J_/t - 7 z- <br /> i =' f _ <br /> r (Complete In Triplicate) 7353 <br /> F Application is hereby °made to the San Joaquin Local Health District for a permit to construct <br /> ands/or install the work herein described. This application is made in compliance with San Joaqui <br /> Co .1. <br /> Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB' ADDRESS/LOCATION L/ZCENSUS TRACT <br /> Owci'er's Name Phone <br /> Zilp- <br /> Addl'i ess <br /> � City <br /> 4r V <br /> Con'tractor's Name r License 4 Phone <br /> TY- ii-OF-WORK. (Check) : NEW WELL / DEEPEN /_% `RECONDITION /_ DESTRUCTION <br /> PUMP INSTALLATION REPAIR /—/ PUMP REPLACEMENT /_7 <br /> i . Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> 1. <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> u <br /> Industrial _ Cable Tool Dia. of Well Excavation XW <br /> Domestic/private: Drilled Dia, of Well Casing _ <br /> Domestic/public Driven Gauge of Casing / <br /> 11' Irrigation Gravel Pack Depth of Grout Seal <br /> r Other Rotary Type of Grout dj <br /> '1 Other Other Information <br /> PUMP} INSTALLATION: Contractor <br /> e Type of Pump H.P. <br /> PUMP, REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ,pES1AUCTION OF WELL: Well Diameter =Approximate Depth <br /> Describe Material and Procedure <br /> ll'. - <br /> I he'reby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and�hhe 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 /> WEL�� D ERS REPORT of the ,well and notify them before putting the well in use. The above <br /> in€oIrma true to the best of my knowledge and belief. <br /> SIGNED TITLE <br /> ' (DRAW PLOT PLAN ON REVERSE SIDE <br /> y1 FOR DEPARTMENT USE ONLY <br /> PRASE I <br /> APPLICATION ACCEPTED BY GC— DATE /� (� 7 y <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE / -! '� 2�/ INSPECTION BY 6�4 DATE ,,� JAS 1Z <br /> CALL FOR A GROUT INSPECTION .PRIOR TO GROUTING AND FINAL INSPECTION. `" - <br /> ' <br /> E11: H 1426 <br /> '1; � 7/72 1M <br />