Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466W-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.,7 �Og <br /> THIS PERMIT EXPIRES .1 YEAR FROM DATE ISSUED Date Issued -- <br /> (Complete <br /> ssued(Complete In Triplicate) DID'7 2-&o--r 7 <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> anal/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 _ _._. SUS TRACT <br /> Owner's Name Phone 'r.z 3 <br /> f <br /> Address <br /> Contractor's Name IBJ License do ;7 Phone36&j + , <br /> TYPE OF WORK (Check): NEW WELL ,&r DEEPEN /—/ '-RECONDITION /_7 DESTRUCTION 17 <br /> PUMP INSTALLATION / ! PUMP REPAIR / / PUMP REPLACEMENT /? <br /> ' Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY �1 <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER Ertl! <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial K Cable Tool Dia, of Well Excavation Jv2 '' ' <br /> Domestic/private `, Drilled Dia. of Well Casing <br /> Domestic/public, " Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> _y Other Rotary �_,,_.Type,of Grout „}. <br /> ---: Other Othe_r Information <br /> PUMP INSTALLATION: Contractor " <br /> - Type-of-Pump. — 'o A..,-e--- .., ..y H.P. <br /> ; <br /> PUMP REPLACEMENT: / / State Work Done <br /> rPUMP REPAIR o = -. -. // <br /> State-Work •Done--- <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 thelSan 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 i✓ TITLE <br /> ( W PLOT PLAN ON REVERSE SID <br /> R DEPARTMENT USE ONLY <br /> PHASE I ' <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GR SPE TI PHASE III/FINAL INSPECTION <br /> INSPECTION BY INSPECTION BY - DATE <br /> CALL FOR A GROUT INS ECTION PRIOR TO GROUTING AND FINAL INSPECTION. 4 <br /> E H 1426 7/72 1M <br />