Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601' E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 72-V <br /> P <br />► APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM- DATE ISSUED Date Issued/e <br /> (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. 3862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION rz CENSUS TRACT <br /> j <br /> owner's Name 1, J Phone Z Q. �i------� <br /> �•. -- <br /> � <br /> Address Sig City <br /> ' 4 --r License # p pPhoae <br /> Contractor s Name 2 AQ�sJ �� 4J - -L <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN / / RECONDITION /_7 DESTRUCTION71 <br /> / <br /> PUMP, INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT / <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 N <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information v) <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT- /l/I State Work Done - C_ r_ '110 y <br /> PUMP REPAIR•- - - / / - State Work Done- <br /> a <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 DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> F information is true to the best of my knowledge and belief. .,. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYl DATZ/e <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA E I I INAL INSPECTI N _ <br /> INSPECTION BY DATE INSPECTION BY - DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> i E 7/72 1M <br /> H 1426 <br />