Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICEUSE: 1601 E. Hazelton Ave. , Stockton, C81il <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR P-UMP PERMIT Permit No. <br /> THIS PERMIT 'EXPIRES 1 YEAR FROM DATE ISSUED Date. Issued. /V - <br /> �^ (Complete In Triplicate) <br /> i's <br /> Application Zere'by made to th(P Sin 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 Joaquiri� <br /> County Ordinance,No. 1862 and'`•the �Rule-sr'-a-nd Regulations of-the San .Joaquin Local health District. <br /> JOB ADDRESS/LOCATION / Y =`--' 4 '� CENSUS TRACT <br /> c fib/ <br /> Owner's tame �_� +� _ '' � �� Phone <br /> n <br /> _ <br /> Address 43 GU. � / 1�. city �,D/ <br /> �s � - - <br /> Contractor's Name License # 14,?37,3 Phone L-La S' <br /> TYPE OF WORK (Check) : yNEW WELL / / DEEPEN / / RECONDITION /_� DESTRUCTION <br /> PUMP INSTALLATION .�/ PUMP REPAIR / / PUMP REPLACEMENT /? <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL C0135TRUCTION SPECIFICATIONS <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 <br /> r PUMP INSTALLATION: Contractor <br /> Type of Pump . H.P. / <br /> F _ <br /> ' PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done - - <br /> s <br /> ESTRUCTION OF WELL: Well Diameter Approximate Dept <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> ' AYS <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN D <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 is true to the best 'of my knowledge and belief. _ <br /> SIGNED TITLE - <br /> RAW PLOT PLAN ON REVERSE SIDE <br /> a FOR DEPARTMENT USE ONLY <br /> PHASE I \01 \0 I na- <br /> SAPPLICATION ACCEPTED BY DATE <br /> ` ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS III. FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE - 2= <br /> CALL FOR A GROUT INSPECTION-PRIOR TO GROUTING AND FINAL INSPECTION. 7/72 1M <br /> E H 1426 <br />