Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT "" �+/�{ <br /> r FOR OFFIgE USE: '`: . ., , 1601 E. Hazelton Ave. , Stockton, :Calif. � �+�+ <br /> I U Telephone: (209) 466-.6781 ' <br />' APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �3 QIP <br /> k <br /> M THIS PERMIT EXPIRES 1 YEAR FROM DATA ISSUED , Date Issued <br /> (Complete In Triplicate) t. <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�,ait&',Ae ulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ' G CENSUS TRACT <br /> I Owner's Name ` Phone <br /> Address 0 City <br /> Contractor's Name _ _ .:, License # 14-7j)3 Phone ydj S <br /> r <br /> TYPE OF`WOkK 7(Gheck) , .14EW WELT; /_'] `DE 'EN /_/ PRECONDITION /� DESTRUCTION <br /> PUMP INSTALLATION lJ PUMP REPAIR f / PUMP REPLACEMENT /? �. <br /> Other ] f <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 .f <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal. � 3 <br /> Other Rotary Type of Grout ' <br /> Other Other Information ' ' <br /> i <br /> : <br /> PUMP INSTALLATION: Contractor- # <br /> e <br /> Type of Pump. _,:..,.... H.P. 3 <br /> PUMP REPLACEMENT:- / / State Work Done <br /> PUMP REPAIR / State Work Done f <br /> f ,DESTRUCTION OF WELL: Well Diameter Approximate Depth 1 <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 FIFTEEI3 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 /> eA <br /> SIGNED &LA14- `iz a�L— - �l�t.G TITLE �t� a.1 <br /> (DRAV PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY G DATE <br /> E ADDITIONAL COMMENTS: - <br /> PHASE II GR&T INSPECTION PHASE III INAL INSPECT ON <br /> INSPECTION BY DATE INSPECTION BY—0DATE `I�l <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 ' 4/72 .- im <br />