Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT ! <br /> FQR.OFPICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Q Telephone: - (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR 'PUMP PERMIT Permit No. 7z.- 1 3 <br /> THIS PERMIT EXPIRES. I' YEAR FROM DATE 'ISSUED Date Issued - 7 7 Y <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.a1862 and the Rules and Regulations of the San Joaquin Local Health District. I <br /> " f <br /> JOB ADDRESS/LOCATION ,,N GULIhs? CENSUS TRACT <br /> Owner's�Name', , Jbe- +LY1 A- <<_. "_: _ Phone "Mr- 412 <br /> $ <br /> Address S City <br /> Contractor's Name License # fa Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/_/ RECONDITION /-T DESTRUCTION /_7 <br /> PUMP INSTALLATION I / PUMP REPAIR / I PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK O SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> 01 <br /> Industrial �_ Cable Tool Dia. of Well Excavation Uq <br /> - Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven -, Gauge of Casing L41 e Ll <br /> Irrigation Gravel Pack Depth of Grout Seal C94WQe4 <br /> Other Rotary Type of Grout <br /> Other " Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump /1.._..F H.P. -' <br /> PUMP REPLACEMENT: /-7 state Work Done­ <br />.;.r PUMP REPAIR-: -State-Work Done <br /> ,pESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Descrite Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the Sail 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 best of my knowledge and belief. <br /> SIGNED ,,,,, TITLEIL <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY <f- DATE fZT 2`- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE Ilj/ NAL INSPECT ON <br /> INSPECTION BY DATE - = INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO_ GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />