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.7Ce" <br /> Y <br /> k THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date IssuedS, - 73 <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 /> Jm'D WA-1 rq 2 M <br /> OB ADDRESS/LOCATION L <br /> 9 CENSUS TRACT <br /> Owner's Name Phone &3E /` W__91_. <br /> Address City 45t- G <br /> Contractor's Name License Phone <br /> TYPE OF WORK (Check) : NEW WELL /� DEEPEN /_� RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT /_7 <br /> Other / / — <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 41 <br /> Industrial Cable ,Tool Iiia. of Well Excavation <br />! Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public. s.�, . Driven Gauge of Casing + <br /> Irrigation Gravel Pack Depth of Grout Seal 4 <br /> Other - (Rotary , , Type of Grout <br /> Other Other Informmation <br />]}fi r ,4 <br /> PUMP INSTALLATION: Contractor t <br /> i <br /> f Type .'of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done' <br /> -PUMP-=REPAIR-: --*ti- /F, rState,Work-Done. - ,"'• ! � ` _ i9,Cl <br /> WELL <br /> ,DESTRUCTION OF : Well Diameter <br /> _ . 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 the best of my knowledge and belief. <br /> SIGNED TITLE <br /> RAW PLOT PLAN ON REVERSE SIDE <br /> ;FOR DEPARTMENT USE ONLY <br /> ' PHASE I ti - � <br /> APPLICATION ACCEPTED BY DATE �`• <br /> '`ADDITIONAL COMMENTS: <br /> PHASE II G UT P TI P I AL INSPECTION <br /> INSPECTION BY DATE INSPE ON ATE -r " -- <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M' <br />