Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICEUSE; 1601 E. Hazelton-Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 7L S5 P <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, <br /> i + 7Z-S�w <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued• 1. 0. 7Z <br /> (Complete In Triplicate) <br /> Application 1s 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 7 T9 <br /> - r .Tk CENSUS TRACT <br /> Owner's Name <br /> Phone cFj,t-.42 (� �� f <br /> Address l/ '7 <br /> City_ ' C� i <br /> Contractor's Name <br /> License #fly Phone i <br /> TYPE OF WORK (Check): NEW WELL' _ /� DESTRUCTION /�] <br /> /)(/ DEEPEN / / RECONDITION <br /> PUMP INSTALLATION PUMP REPAIR '/.`{/ PUMP REPLACEMENT /? <br /> l Other !/ / F r <br /> f x _ <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES . PIT PRIVY <br /> SEWAGE DISPOSAL FIELD-`.- CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> _ Industrial K Cable Tool Dia. of Well Excavation .. . �� <br /> _ Domestic/private i Drilled Dia, of Well Casing •--1 <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation € Gravel Pack Depth of Grout Seal <br /> Other <br /> i Rotary Type of Grout <br /> 1 Other Other Information <br /> � f <br /> PUMP INSTALLATION: . Contractor L.�,c 01 <br /> Type of Pump ` <br /> H.P. 2f� <br /> PUMP REPLACEMENT: ' <br /> State Work Done <br /> PUMP REPAIR: J% State Work Done + <br />.DESTRUCTION OF WELL: Well. Di meter <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 f <br /> after completion of,my work onja 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 s <br /> TITLE c, <br /> (D W PLOT PLAN ON REVERSE SIDE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE 1� �[� <br /> ADDITIONAL COMMENTS: '" 9 <br /> PHAS 0 T NSP ION II <br /> INSPECTION BY f PHASE III FINAL INSPECTION <br /> DATE 1, �/ INSPECTION BY DATE <br /> CALL FOR A � <br /> PECTION PRIOR TO GROUTING AND FINAL INSPECTION. R <br /> B H 1426 7/72 1M <br />