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. 7 2- (o <br /> 01� THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In_Triplicate) <br /> A licatibrf is hereb <br /> pp y 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 'Z 3pL CENSUS TRACT <br /> Owner's Name Phone 2 <br /> Address City <br /> Contractor's Name WAn Ras License # f` Phone <br /> TYPE OF WORK (Check): NEW WELL74 DEEPEN/% RECONDITION /7 DESTRUCTION /- <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMI REPLACEMENT /7 <br /> Other /-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK /317 SEWER LINES ( 2,%i 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: J / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ,pESTRUCTION 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�thbbof my knowledge and belief. <br /> a h <br /> SIGNED r TITLE 74Z R h <br /> AN ON REVERSE SIDE <br /> FOR DEPARTMENT_ USZ ONLY <br /> PHASE I <br /> APPLICATION ACCEnZD BY E <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS INAL INSPECTION <br /> INSPECTION BY DATE >-J 7-- 122, INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />