Laserfiche WebLink
OFFICE USEr1SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> : <br /> 601 E. Hazelton Ave. , Stockton, Calif. "' <br /> * � \ Telephone: (204) 466--6781 A <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. _6 f7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued � ' 23 - 7 y <br /> ` (Complete In Triplicate) <br /> ica�tion is hereby made to- the San Joaquin Local Health District for a permit to construct <br /> or install the work herein described. This application is made in compliance with <br /> P San Joaquin <br /> znty Ordinance No. 1862-errd the Rules and Regulations of the San -Joaquin Local Health District. <br /> 'ADDRESS/LOCATION S' v <br /> i CENSUS TRACT <br /> ier's;Name , Phone <br /> Fess S <br /> City <br /> i ractor's Name ,� S License �� <br /> i1 Phone -,,� I <br /> f 4 _ <br /> ?E OFE!.WORK (Check) : NEW WELL / / DEEPEN / f RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION /7/ PUMP REPAIR ,/—/ PUMP REPLACEMENT /_7Other <br /> ' NCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER *mom . <br /> INTENDED USE TYPE OF WELL <br /> CONSTRUCTION SPECIFICATIONS <br /> _ Industrial Cable Tool Dia. of Well Excavation f <br /> Domestic/private Drilled Dia. of Well Casing <br /> _ Domestic/public Driven <br /> ,f Gauge of Casing <br /> e-- Irrigation Gravel Pack Depth of Grout Sea <br /> f - l.Other Rotary y Type of Grout <br /> Other Other.Information <br /> 1 <br /> _..FINS+TALLATION: Contractor O� <br /> Type of Pump <br /> H.P. <br /> REPLACEMENT: /�/ State Work Done <br /> REPAIR: State Work Done &�2 r%2 �h/�S r 10V' <br /> !� ! ._ <br /> ;RUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i: rebyaagree to comply with all laws and regulations of the San Joaquin Local Health District � <br /> I the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> "r completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> :ormation is true to the best of my knowledge and belief. <br /> 17_� <br /> (DRAW PLOT LAN ON REVERSE SID <br /> Ste'. I FOR -PARTMENT USE ONLY <br /> '_KATION ACCEPTED BY DATE i <br /> )ITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> i :CTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> F-H 1426 4/72 1M <br /> 1 <br />