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 /> 7y <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> I (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 Joaquit <br /> County 0 din ce �8�62aiAd toe Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDSS LOCAY Y. ..S r �, T� R F 1� ct 41. C o 4,t 12 �1 c. CENSUS TRACT <br /> Owner's Named ICK S Phone <br /> l � <br /> I Address 4,O 2 ft K v.,1� S.( City �cf� o <br /> i ,�..•_ - <br /> Contractor's Name 6 £� ( /`f �c. � License 3 �!T <br /> - Y6.z_ 373 Phone <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /~� RECONDITION /- DESTRUCTION <br /> PUMP =INSTALLATION /? <br /> _ ��PUMP REPAIR / /,' PUMP REPLACEMENT /-7 <br /> Other'.. <br /> DISTANCE TO NEAREST: SEPTIC; TANK oSEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 7S- - CESSPOOL/SEEPAGE*PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial -Cable .Tool.. Dia.--of� Well Excavation <br /> _ <br /> -Domestic/private Drilled Dia. of Well Casing rr <br /> Domestic/public 1 Driven Gauge of Casing /0 <br /> Irrigation I Gravel Pack Depth of Grout Seal o <br /> Other <br /> I ay Type of Grout <br /> Other ��. <br /> Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump s'` 1. <br /> H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ESTRUCTION 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 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 <br /> DRAW PLOT PLAN ON REVERSE SIDA _ <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE �4 SQ- %E <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY d:i. 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 />