Laserfiche WebLink
to . <br /> SAN JOAQUIN LOCAL HEALTH :DISTRICT <br /> FOR OFFICE USE: 1641 E., Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) '466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR, PUMP PERMIT Permit No. 7Z, 7µr <br /> THIS PERM IT .EXPIRES 1 YEAR 'FROM.-DATE 'ISSUED , Date Issued 7- y 7 Y <br /> (Complete In Triplicate) OSF — 2�p <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 with San Joaquin is <br /> County Ordinance No. 1862 and the Rules a- q <br /> nd Regulations of the San -Joaquin Local Health District. 1 <br /> � 457- , ! <br /> JOS ADDRESS/LOCATION - - CENSUS TRACT S 7 <br /> Owner's Name Phone ` <br /> Address Lj ` City <br /> Contractor's Name , License #/6 2A 73 Phone <br /> TYPE OF WORK (Check): NEW WELL -/_7 DEEPEN /_7 RECONDITION /� DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIRPUMP REPLACEMENT /7 <br /> Other L-1 <br /> DISTANCE TO NEAREST: SEPTIC TANK, SEWER LINES PIT PRIVY ! <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION 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 /> � 2S_ Irrigation Gravel, Pack Depth of Grout 'Seal �. <br /> Other Rotary Type of Grout . <br /> Other Other Information ;- . . <br /> PUMP"INSTALLATION; Contractor ! <br /> Type"of Pump A H.P. <br /> PUMP REPLACEMENT: <br /> / / :.State Work,Done <br /> w 1 5 - <br /> PUMP REPAIR: State Work-Done <br />,DESTRUCTION OF WELL: R Well Diameter 4 , �/ 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 newwell, 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 <br /> TITLE i <br /> W PLOT PLAN ON REVERSE SIDES FOR DEPARTMENT-USE -ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY�� DATE - <br /> ADDITIONAL COMMENTS: ' <br /> PHAS II GR PE ON PHASE II1/FINAL! INSPECTION <br /> INSPECTION BY UDATE _F INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO�GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 IX <br />