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. 7Z-- 1/8 <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued <br /> i (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 Q Al 0 CENSUS TRACT <br /> F � <br /> Owner's- Name V - Phone .2 <br /> Address �4070 City <br /> Contractor's Name License #/ hone X 676 <br /> TYPE OF WORK (Check) : NEW WELL /7 DEEPEN /_7 RECONDITION /7 DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR jC'/ PUMP REPLACEMENT /_7 <br /> Other / / T <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> a <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> — +_ Domestic/private Drilled Dia. of Well Casing 1 <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout ^� <br /> Others Other Information <br /> 1 <br /> I ?` <br /> 1 PUMP INSTALLATIONS Contractor <br /> I! Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / State Work Done <br /> ESTRUCTION OF WELL: Well Diameter 'Approximate Depth <br /> Describe Material and Procedure <br /> i 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 knowledg and belief. <br /> SIGNED app : TITLE s- <br /> DRAW LOT PLAN ON' VERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �: J <br /> APPLICATION ACCEPTED BY C DATE <br /> ADDITIONAL COMMENTS: 71 <br /> PHASE II GROUT INSPECTION PHASSAilal4v INSPECTION <br /> INSPECTION BY DATE INSPECTION #BY " DATE 4 _CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL IN <br /> E H 1426 7/72 1M <br />