Laserfiche WebLink
SAN JOAQi3IN LOCAL "I11ATH DISTRICT <br /> FOR OFFICE USE: 1601 F. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 ' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No- 7 Z- 15 S <br /> THIS PERMIT EXPIRES I YEAR FROM'DATE ISSUED : Date Issued •7 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San. Joaquin Local Health District for a permit to construct i <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 Re, 7 latio s of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION62, �Q-a � CENSUS TRACT -Z/ <br /> i <br /> Owner's Name <br /> Phone ' # <br /> Address <br /> ' City <br /> Contractor's Name 4 License ���/�hone`' G� <br /> TYPE OF WORK,(Check) : " NEW .WELL DEEPEN / / RECONDITION /.;.7- DESTRUCTION /-7 x _= <br /> PUMP INSTALLATION PUMP REPAIR / I PUMP REPLACEMENT /? k <br /> . Other / _7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY i <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT ' OTHER <br /> i <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 i Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary j ' Type of Grout P • <br /> Other i Other .-Information <br /> PUMP INSTALLATION: Contractor �+ <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: ! .,/ / 4"State Work Done - <br /> L--;DESTRUCTION OF WELL:. 'rWell 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 noiify them -before putting the well in use. The above <br /> information is true to'`the best of my.•knowledge and belief.' <br /> SIGNED c� TITLE <br /> C (DRAW PLOT ULAN ON REVERSE SIDE) <br /> : FOR DEPARTMENT USE ONLY , <br /> PHASE I <br /> 1" ' <br /> APPLICATION ACCEPTED BY D DATE p9 <br /> ADDITIONAL COMMENTS: ; <br /> PHASE--II GROUT INSPECTION V - r .-PHASE III-/FINAL-INSPECTION <br /> INSPECTION BY DATE r. INSPE TION BY, DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 r 4/72 1M <br />