Laserfiche WebLink
T ry SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1.601. E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /a <br /> f (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 Lt/� RW <br /> f -e / NSU5 TRACT <br /> Owner's Name Phone 7�0 <br /> Address 12 _26, 7 '7 CityEfy_�_u <br /> Contractor's Name A_J License ��j 3 7,3Phone� <br /> TYPE OF WORK (Check) . NEW WELL / / DEEPEN /_7 RECONDITION /_7 DESTRUCTION /_7 ; <br /> PUMP INSTALLATION / / PUMP REPAIR �-f PUMP REPLACEMENT /_ e <br /> Other /_7 T <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 /> g -Domestic/private Drilled Dia. of Well Casing _ <br /> Domestic/public Driven Gauge of Casing <br /> X Irrigation _ Gravel .Pack - , .. .Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor hJ <br /> Type of Pump,_ H.F. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: State Work Done <br />.pESTRUCTION OF WELL: Well Diameter pproximate Depth r <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 TITLE t <br /> (DRAW PLOT PLAN ON REVERSE!.SIDE ry <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 6 E <br /> APPLICATION ACCEPTED BY , ,� ------- DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE , INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M C� <br />