Laserfiche WebLink
V <br /> 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 /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 2 .vj8EE4idC� CENSUS TRACT S N 7 <br /> Owner's Name Phone 3 IQ--.OZ<yp <br /> Address 7a7 City <br /> Contractor's Name ' <br /> ttt. License #/_A690 Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION /_7 DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY �V <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED SE TYPE OF WELL CONSTRUCTION SPECIFICATIONS N.J . <br /> Industrial Cable Tool Dia. of Well Excavation 3 <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven 4- Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal ' <br /> Other Rotary Type of Grout <br /> ' Other Other Information <br /> PUMP INSTALLATION: <br /> Contractor , ro <br /> Tyypper of Pump p H.P. <br /> PUMP REPLACEMENT: State Work Done ! <br /> 42 42 <br /> PUMP REPAIR: /% State Work Done <br />,DESTRUCTION 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 Hedlth District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information i true to the best of my knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE '7 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION., <br /> E H 1426 7/72 1M <br />