Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: j 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone:: <br /> p (209) 466-67$1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. - /S a <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In <br /> Application is hereby made to the SanJoaquin Triplicate) <br /> 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 �-,q .0 ®S L 717 !2 c A M CENSUS TRACT <br /> Owner i s Name _!g,&NA 9-..A&,1 IVC 12 4r, A 4 /V o 9,e iZ& i�- Phone c <br /> 2- Ocr <br /> Address d u. !fps ? A 7 CAri city S ZIely -- - <br /> Contractor's Name License # i b p 7,(,Phone 4t.tf <br /> TYPE OF WORK (Check) : NEW WELL /-7 DEEPEN /-7 RECONDITION /-7 DESTRUCTION /7 <br /> PUMP INSTALLATION PUMP REPAIR Z -PUMP REPLACEMENT /7 <br /> Other / / -- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PTT PRIVY o) . <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 Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump u 1Z 13 /h/ H,p. 30 /-70 <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: State Work Done <br /> 01 <br /> .RESTRUCTION 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 /> 3L TITLE <br /> {DRAW PLOT ON REVERSE SIDE <br /> PHASE i <br /> FOR DEPARTMENT USE ONLY <br /> � - <br /> APPLICATION ACCEPTED BY \\ DATE <br /> ADDITIONAL COMMENTS: } <br /> PHASE II GROUT INSPECTION PHASE I 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 IM <br />