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. - „2Q8lJ <br /> 72 - .2 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 12 7� —2- <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 /> ovJTG� <br /> JOB ADDRESS/LOCATION -- /7�G,zS, .�� .,, i,/ CENSUS TRACT <br /> Owner's Name Phone <br /> Address -/J6-,L^ City/1Yuz.- � Ci1,X <br /> Contractor's Name aja cif- License #JZ�Z$Phone, a- <br /> �J <br /> TYPE OF WORK (Check): NEW WELL /r DEEPEN /-7 RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION _N/ PUMP REPAIR / / PUMP REPLACEMENT /� <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 a _ <br /> Z Domestic/private _jG Drilled Dia. of Well Casing ,J <br /> Domestic/public Driven Gauge of Casing oc <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Other /—Rotary Type of Grout 4- <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 ”, - , TITLE <br /> RAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 1� L%� <br /> APPLICATION ACCEPTED BY DATE J2 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BYw `� .. DATE , <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 / 3 6 <br /> '7-P7/72 1M �. <br />