Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR O=CF USE: 1601 E. Hazelton Ave. , Stockton, Caf. 'J r��t <br /> " Telephone: (209) 466-6781 <br /> ICATION FOR WELL CONSTRUCTION OR PUMP ERM Permit No. 7 Z 5 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 4.z 0 7 L <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 Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ,�r . �- CENSUS TRACT <br /> Owners NamePhone <br /> Address �� � �' ��.��� �� -•� <br /> City <br /> /`� License # 16:13 Phone4(1/,_ T <br /> Contractor's Name , ���'� 1 .L�-n.�,�.� ��f',tk, .3 1 �� <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION /_/ DESTRUCTION <br /> PUMP INSTLATION PUMP REPAIR/ / PUMP REPLACEMENT /=T <br /> AL <br /> 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 <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <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: / / 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 ����7� ,a, ti��i:r�' vn -� TITLE ���L �y. ��g �= •:; <br /> V (DRAW PLOT AN ON REVERSE SIDE) <br /> FO DEPARTMENT USE ONLY <br /> PHASE IJ_ DATE <br /> y�APPLICATION ACCEPTED B '� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FIN NSPECT N �✓ <br /> INSPECTION BY DATE INSPECTION BY DATE 2 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />