Laserfiche WebLink
• SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: V/ 1601 E. Hazelton Ave. , Stockton, Calif.+ <br /> Telephone : (204) 466--6781 a�C„A11jrATC-D 6 - 3 - w <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 6' �f <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 <br /> Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION q5.2-[.- <br /> CENSUS TRACT <br /> Owner's Name [o r,� -�,, Phone <br /> Address 7 �d �� / � City <br /> Contractor's Name Grcc /� > License # Phone <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /_% RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other /—/ <br /> DISTANCE TO NEAREST: SEPTIC TANK /d-c> 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 �e <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal �C2 <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor f <br /> Type of PumpIKZi H.P. z <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> .RES_TR_UCTION 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 REPOR the well and notify them before putting the well in use. The above <br /> informati is a st o y knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> F R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED B .� DATE <br /> ADDITIONAL COMMENT <br /> P I O T INSPECTION PHA N INSPECTION <br /> INSPECTION BY DATEINSPECTION BY DATE _,Z - <br /> CALL FOR A, SPECTION PRIOR TO GROUTING AND FINAL INSPE <br /> E H 1426i -//V 7/72 1M <br />