Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Haeel,tori-'Ave:, Stockton, Calif, <br /> Telephone,-,,,- (2p9) :�[�66`-6781 <br /> APPLICATION FOR WELL CONSTRUCTION"OR PUMP PERMIT Permit No. �J <br /> THIS PERMIT EXPIRES, YEAM FROM DATE 'ISSUED , <br /> ' �Z 6 vtita� - Date �I s s ue d <br /> ���d� -r (Complete In ,Triplicate} ;;t 1. s <br /> Application is. ,hereby;made to .the,,San-Joaquin- L-ocal .Health Dis.txiatl foar,'a$permit' to construct <br /> and/or install the work herein described. This appl+icationvi's'mad'e-•in;compliance-with• San's7oaquir <br /> Coun'ty.,Or,dinance`)No,.g1862.�andr,the Rules:i <br /> and;Regulations°•o£,.{the San°Joaquin"Local'+Health' District. <br /> JOB ADDRESS/LOCATION <br /> ';,CENSUS-- i�.S (1, b <br /> owner". uH ex # 54 - 74,j �u . <br /> '''s�.Name~�`` � 'tik.' <br /> t e :Phone, -&.61' <br /> !Address <br /> . _.__... _ City <br /> Contractor's Name ` - _ <br /> Licens r <br /> PhoneeS <br /> `TYPE"OFTWORK"(Check);""NEW-WELL / / DEEPEN :_.�_� _ ._ ._.�� <br /> _ � / RECONDITION /_7 DESTRUCTION /7 <br /> i PUMP INSTALLATION PUMP REPAIR '/ I PUMP REPLACEMENT /? <br /> Other. /_7 <br /> r <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> a PIT PRIVY <br /> s. SEWAGI; DISPOSAL, FIELD` CESSPOOL/SEEPAGE PIT OTHER <br /> i <br />( INTENDED 'USE TYPE OF WELL <br /> f c Industrial' _ CONSTRUCTION SPECIFICATIONS <br /> Cable Tool D a..-of_Well Excavation <br /> !� Domestic/private Drilled <br /> Domestic. Dia. of Well Casing <br /> /p:ublic Driven gauge of Casing= <br /> Irrigation, Gravel Pack Depth of Grout Seal <br /> Other <br /> Rotar <br /> • - _.. . _._ �. y TYPe s of Grout <br /> �Othe`r� <br /> j- <br /> __0 <br /> ther.'InforTdation " <br /> 1 <br /> PUMP INSTALLATION: Contractor 4i <br /> I. Type of Pump I <br /> H.P.; p ' <br /> PUMP REPLACEMENT: <br /> / / State Work Done <br /> PUMP REPAIR: <br /> / State Work Done 9 <br /> ,DESTRUCTION OV WELL: Well Diameter <br /> c! Describe Material and Procedure Approximate Depth <br /> I hereby agree to comply with all Taws and regulations of the an Joaquin Local Health District <br /> and :the State' of; California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completon''of my work on a new well, I will furnish the San Joaquin Local Health District <br /> WELL DRILLERS "REPORT of the well and notify them before putting the well in use. The above <br /> information it true to the best of my knowledge and belief. If � <br /> SIGNED <br /> TITLE <br /> { (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE <br /> PHASE 11 GROUT INSPECTION <br /> INSPECTION BY PHASE III/FINAL-INSPECTION <br /> DATE INSPECTION BY DATE <br /> CALL JOR A GROUT„INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 . <br /> 4/72 `19 s <br />