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. ,;�2_0 <br /> THIS PERMIT. EXPIRES 1 YEAR FROM DATE ISSUED Date issued <br /> (Complete In Triplicate) <br /> Application is hereby made tosthe 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 andthe Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION i 'CENSUS TRACT <br /> Owner's Natm?. _ .� �. �� f���/� /Is ._,_..� Phone <br /> Address A )( city S7e4&7-,91)1 <br /> Contractor's Name 4.14j ,� •� �(�( / CJ', License # L C�Z Phone 414Z <br /> TYPE OF WORK (Check) ; NEW WELL DEEPEN /�/ RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR /—/ PUMP REPLACEMENT /_7 <br /> Other <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 /> Irrigation Gravel Pack ` ``'Aepth of Grout Seal ( <br /> Other . .� Rotary Type e of Grout <br /> �i�/°'�- ��/ <br /> Other Other Information <br /> PUMP INSTALLATION:, Contractor yko� <br /> Type of ;Pump H.P. <br /> PUN? REPLACEMENT-'- / / S tate Work:.-Done <br /> PUMP REPAIR: <br /> / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter _ . , Approximate Depth <br /> - -- Describe Material and Procedure <br /> A <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 /> / , k <br /> SIGNED _ , _ TITLE k .� <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I - N <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: ; <br /> PHASE II GROUT INSPECTIO 4� I d� 3,� RASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECT' Y DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 IM <br />