Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. r <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No./2_/7� P <br /> r � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED. Date Issued <br /> 1t (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 <br /> Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 1��cr 7" Gam, � CENSUS TRACT <br /> Owner's Nath Phone <br /> Address <br /> City <br /> Contractor's Name �1Y �iC�t �i+�s� License #A,.23 7_3Phone 3 <br /> TYPE OF WORK (Check) : NEW WELL /_7 DEEPEN /`T RECONDITION /77/ DESTRUCTION /7 <br /> PUMP INSTALLATION / _/ PUMP REPAIR �PUMP REPLACEMENT /_7 <br /> Other <br /> . r <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 /> - - - <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 ' � i • _ <br /> 54 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump �" H.P. <br /> PUMP REPLACEMENT: / `/ State Work Done <br /> PUMP REPAIR..-- State Work Done - - - -d <br />.ESTRUCTION 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 ponstruction. Within FIFTEEN DAYS � <br /> after completion of my work on alenew 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. �A <br /> SIGNEDTITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE), <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ' <br /> APPLICATION ACCEPTED BY Z-- DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROW I P TIO PHASE II /FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE - p^7-,_:' <br /> CALL FOR A GROUT INSPECTION .PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 IM <br />