Laserfiche WebLink
'SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. "Stockt6n, -Calif. <br /> F 00 -i D 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 AuZ <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 /> F <br /> County Ordinance No: 1862 and the Rules nd Regulations of the San Joaquin Local Health District. <br /> j. JOB ADDRESS/LOCATION L —- -rJ �Q � CENSUS TRACT <br /> Owner's Name Phone <br /> iI Address _. -- - . � - -r.] /7- 1- �7C�ivz� City <br /> Contractor's Name 1.� �. .si License G O.&hone <br /> V TYPE OF WORK (Check): NEW WELL / / DEEPEN / / RECONDITION /_7 DESTRUCTION /_7 <br /> ru PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> S' <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 N <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 <br />' Other Other Information 1 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: J / State Work Done i <br /> I ,PESTRUCTION OF WELL: Well 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 notify them before putting the"well in use. The above <br /> information-.s true `to the best of my knowledge and belief. O <br /> SIGNED �` ,n L IGL � TITLE <br /> r (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I f <br /> APPLICATION ACCEPTED BY .j DATE <br /> ADDITIONAL COMMENTS: /6.2 rQ 6 Zo <br /> PRASE. Ij GR UT INSPECTION PHA E' III/FINAL INSPECTION <br /> INSPECTION BY DATE GD INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR. TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />