Laserfiche WebLink
., <br /> / SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR 0 FICE USE: ,/ 1601 E. Hazelton Ave. , Stockton, Calif. <br /> yy Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 <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 Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION g xJ (�[ CENSUS TRACT <br /> Owner's Name Phone <br /> Address <br /> City <br /> Contractor's Name <br /> /,.s License # Phone ��• <br /> f TYPE OF WORK (Check): NEW WELL /7 DEEPEN /7 RECONDITION /- YDESTRUCTION /7 <br /> PTJ4,INSTALLATION / -/ _ PUMP REPAIR / / PUMP REPLACEMENT /2;E-- <br /> Other --- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE .DISPflSAL FIELD -C <br /> ESS PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private-% ' i Drilled `" Dia. of Well Casing <br /> Domestic/public , Driven, - Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal t <br /> Other Rotary Type of Grout ac] t <br /> Other Other Information ' <br /> N <br /> PUMP INSTALLATION: Contractor <br /> lyType of Pump H.P. Q F <br /> PUMP REPLACEMENT: / State Work Done47) <br /> PUMP .REPAIR:- 64C7, <br /> ./�/ ..rS to to Work Done _ _ - <br />.RESTRUCTION_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 bes of my knowledge and belief. 4 <br /> SIGNED NI <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �� <br /> APPLICATION ACCEPTED BY DATE /dZ /5– 7 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II OUT INSPECTION PHA F INSPECTION <br /> INSPECTION BY DATE INSPECTION BY <br /> CALI. F - <br /> OR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br /> . ,w„ ,•r•. x.�. - .. ,". . . Kip'. -.. ". ,. XT. 'tY" '� .... „q,_. .,. .. r,,,,,i. - - ..: <br />