Laserfiche WebLink
SAN JOAQUIN LOCAL IEALTH DISTRICT 7 <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. � <br /> V THIS 'PERMIT EXPIRES 1 YEAR FROM DATE ISSUED : Date Issued &--az--ZZ- <br /> (Complete In Triplicate) <br /> Application is hereby made tothe San Joaquin Local Health District for a permit to construct <br /> is made in compliance with San <br /> in <br /> and/or install the <br /> work herein described. This application trict. <br /> and Regulations of the San Joaquin Local Health D <br /> County Ordinance No. 1862 and, the Rules s <br /> ' CENSUS TRACT <br /> JOB ADDRESS/LOCATION <br /> Phone ' <br /> Owner's Name v d <br /> city <br /> Address - �! <br /> License J,�p�Phone --CJ <br /> Contractor's Name <br /> 1 <br /> TYPE OF WORK (Check) : NEW WELL; DEEPEN /? RECONDITION /_� DESTRUCTION �T <br /> PUMP 'I -P PUMP REPAIR J^I Pt MP�R�PLACEMENT %� <br /> - _ - <br /> Other / / <br /> SEWER LINES PIT PRIVY <br />} DISTANCE TO NEAREST: SEPTIC TANK CESSPOOL/SEEPAGE .PIT, , OTHER. <br /># SEWAGE DISPOSALFIELD <br /> T <br /> INTENDED USE TYPE OF WEL CONSTRUCTION SPECIFICATIONS <br /> ' Cable Too1 Dia. of Well Excavation <br /> IndustriaDrillel Dia, of Well Casing <br /> Domestic/private Drivend Gauge'of Casing117 <br /> Domestic/public <br /> Irrigation Gravel Pack Depth of Grout Seal 41 ' <br /> I Type of Grout <br /> Other <br /> Rotary -� <br /> Other Other Information <br /> k <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type of Pump <br /> PDMP,REPLACEMENT: -• / / State Work Done <br /> E _ _ <br /> PUMP REPAIR: / / State Work Done <br /> ESTRUCTIONOF W$LL: We11Diameter <br /> Approximate Depth <br /> Describe Material and Procedure <br /> 1 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 /> k after completion of my work on a new well, I will furnish the San' Joaquin Local Health District a . <br /> ` WELL DR!:=ME1u1Ljj' <br /> ify'them before putti�he well in use f 8 e <br /> informao edge and belief. <br /> ,SIGNED <br /> W PLOT PLAN ON REVERSE SIDE) <br /> gL <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE - Zr a 2 <br /> APPLICATION ACCEPTED BY <br /> j ADDITIONAL COMMENTS: t PHASE III FINAL INSPECTION <br /> PHAS II GROUT I SPECTION INSPECTION BY DATE <br /> INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> 4/72 1M <br /> E H 1426 <br />