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. <br /> ' 73172� <br /> TMS PERMIT EXPIRES 1 YEAR FROM DATE ISS[TED <br /> Date Issued, �-? <br /> Application is hereby made t� the San (Complete In <br /> Local Triplicate) <br /> and/or install the work herein described. This application 'is made inrcompliancetwithnSan uJoaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION � <br /> +� CENSUS TRACT <br /> Owner's Name. <br /> � Phone <br /> Address � � / <br /> yi <br /> City <br /> Contractor's Name y) �� <br /> License # Phone k <br /> TYPE OF WORK Check): <br /> ( NEW WELL / / DEEPEN J RECONDITION /-7 DESTRUCTION /- <br /> PUMP INSTALLATION /�/,. PUMP REPAiR'z/ / PUMP REPLACEMENT /-7 <br /> Otherf/ / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> SEWAGE DISPOSAL FIELD PIT PRIVY <br /> CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE <br /> TYPE OF WELL <br /> industrial CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic ` <br /> /public i Driven Gauge .of Casing aN <br /> Irrigation I Gravel Pack Depth of Grout Seal <br /> Other i Rotary Type, of Grout <br /> r I Other Other Information <br /> PUMP INSTALLATION: <br /> Contractor *--�. <br /> ` <br /> it + <br /> Type of Pump <br /> r _ H.P. P <br /> PUMP REPLACEMENT: <br /> State Work Done <br /> PUMP REPAIR: ZLV State Work Done Q�a <br /> 2E TRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth _ <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 <br /> n Joaql <br /> WELL DRILLERS REPORT of the well and notify them before putting athe wellninocause. Thehaboverict a <br /> information is true to the best of my knowled, ae nd belief. <br /> � 1 <br /> SIGNS a c.� <br /> �VERsv <br /> TLE <br /> ( RAW PLOT PLAN ON SIDE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY t <br /> 9'P ATION ACCEPTED BY <br /> WITIONAL COMMENTS: DATE <br /> INSPECTION BY <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPECTIONDATE INSPECTION BY <br /> DATE � 3 <br /> CALL FOR A GROUT INSPECTION. PRIOR TO GROUTING AND FINAL INSP ION. <br /> E H 1426 <br /> 7/72 IM <br />