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. Zf,-3,,-74,) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued '-7-3 <br /> '-73 <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 2 7 6411 , CENSUS TRACT <br /> Owner's Name Phone <br /> Address / City -� . <br /> Contractor's Name License # 7LG Q2Q2 Phone yC�2 <br /> TYPE OF WORK (Check): NEW WELL /7[ DEEPEN /-7 RECONDITION /-7 DESTRUCTION /-7PUMP INST TION /—/ PUMP REPAIR /—/ PUMP REPLACEMENT /7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPO AL FIELD CESSPOOL/SEEPAGE PIT OTHER v <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br />_ Industrial Cable Tool Dia, of Well Excavation /Q <br /> _ Domestic/private Drilled Dia. of Well Casing G <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal 50 <br /> Other Rotary Type of Grout �r <br /> Other Other Information <br /> >/ <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 the well and notify them before putting the well in use. The above <br /> informatioti,is 'tr?e`t he best of my knowledge and belief. <br /> SIGNED / v TITLE [f <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: rte' <br /> PHASE I GROUT INSPECTION PAO I InNAL INSPECTI <br /> INSPECTION BY DATE �-Z]-,� INSPECT B DATE - <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />