Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazel--A,'e. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> E� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No."13- 1-11Vj <br /> f - <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -3 <br /> 1 (Complete In Triplicate) <br /> Application is hereby made !to -the San Joaquin Local Health District for a permit to construct <br /> I and/or install the work herein described. This application is made in compliance with San Joaquil <br /> ' County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 170 -7 %. CENSUS TRACT S <br /> Owner t s Name Phone 3 L r2_6:�,,-3 - <br /> r <br /> M <br /> Address /7 CityQf _ <br /> I Contractor's Named License # Phone <br /> TYPE OF WORK (Check) ; NEW WELL /�/ DEEPEN RECONDITION /_� DESTRUCTION /� <br /> PUMP INSTALLATION / / UMP REPAIR / / PUMP REPLACEMENT /_ <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT ` OTHER <br /> INTENDED .USE ITYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial _._XCable Tool Dia. of Well Excavation fz <br /> Domestic/private Drilled Dia. of Well Casing /M& M __ <br /> Domestic/public Driven Gauge of Casing - <br /> _ Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> 3 Other _ Other Information Q <br /> k PUMP INSTALLATION Contractor <br /> Type' of Pump H.P. <br /> PUMP REPLACEMENT: L/ State Work Done <br /> PUMP.REPAIR: . State Work-Done <br /> „DESTRUCTION 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 DRIL PORT of the well and notify them before putting the well in use. The above <br /> informa on t e to t of my owledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FO DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED B DATE 'E/— /,3 "7-3 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT: INSPECTION PHASE II NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A. GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. KO� <br /> E H 1426 7/72 1M <br />