Laserfiche WebLink
�� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 5OR6FFIC� USE: -0' 1601 E. Hazelton Ave. Stockton, Calif. <br /> a <br /> . <br /> Telephone: (209)' 466-6781 <br /> ' - APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �3 <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 1 C y : <br /> CENSUS TRACT <br /> Owner's Name ell ,�- Phone <br /> AddressJ�aC)a City S <br /> Contractor s Name C,(/t j� �( t / License &1, Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /7 RECONDITION /-7 DESTRUCTION !VS' <br /> PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other /_7 <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 Q + <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> 2ESTR_UCT_ION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <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 />:ELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> Enforma s t a to- the best of my knowledge and belief. <br /> UGNED TITLE . <br /> f (DRAW PLOT PLAN ON REVERSE SIDE <br />'RASE I FOR DEPARTMENT USE ONLY, <br /> XPLICATION ACCEPTED BY DATE <br />►DDITIONAL COMMENTS: <br /> P E II ROUT NSPECTION PHASE III FINAL` NSPECTION <br /> INSPECTION BY TE INSPECTION BY TE <br /> CALL FOR A GROU INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 <br />