Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR-OFFICE USE: 1601 E. Hazelton Ave. Stockton, Calif. <br /> Telephone:.' '(209),'466-6781 <br /> I PA.L APPLICATION FOR WELL­CONSiRUCTION'.OR PUMP PERMIT Permit No. 72 <br /> THIS PERMIT EXPIRES 1,YEAR!'FROM DATE ISSUED Date Issued/--)y-71 <br /> (complete In Triplicate) <br /> Application3is-herebysmadetto .th-e�San,-iJoaquin'Local Health Dist-rict; 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.q 1862,:_'and(,th6--.-Rule s'.;and Regulations--of�-the. San Jcruin Local Hdalth-District. <br /> >a <br /> ;0, 3 470 <br /> JOB ADDRESS/LOCATION CENSUS' TRACT <br /> T') <br /> J <br /> Owner's Namq,� Phone <br /> Address City <br /> Contractor's Name License &?Z <br /> Phone, <br /> TYPE OF WORK (Check)'i_ NEW Wfff. /N DEEPEN RE�ZQND.IT.ION.-/— ___.--7-,DESTRUr-T.I-ON ,/—�- - <br /> — <br /> PUMP NST LATION PUMP REPAIR '/ / PUMP REPLACEMENT /7 I <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- Ap�ribximdte 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 DAY.S <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health Districi 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 knoedge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE / e .7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUTINSPECTIONPHASE III FINAL INSPECTION <br /> INSPECTION BY DATE j --2.3 INSPECTION BY DATEM <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E -k I - - - - I— . ly- <br /> H 14�6_- 4/72 IM <br />