Laserfiche WebLink
k <br /> SAN JOAQUIN LOCAL ALTH DISTRICT <br /> to 123 <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 1dY�� Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. , . Ylo <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> ' " (Complete In Triplicate) 26e,-350—0S <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 of the San Joaquin Local Health District. <br /> l673:s`E.: <br /> JOB ADDRESS/LOCATION �.' ^� <br /> CENSUS TRACT 7 <br /> Owner's Name <br /> Phone <br /> Address <br /> city <br /> Contractor's Name License # <br /> Phone <br /> AOL <br /> TYPE OF WORK (Check): NEW WELL DEEPEN / / RECONDITION /_/ DESTRUCTION /_ <br /> PUMP INSTALLATION _.C_T pUMp REPAIR / / PUMP REPLACEMENT /_7 <br /> Other 1/ / <br /> `I <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER V <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 i <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pu H.P. 2, <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> 4 <br />,pESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> T 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 abolfe <br /> information is true to the best of my know dge and belief. <br /> SIGNED <br /> TITLE Cs�i <br /> (DRA LOT P `ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY ` <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE GROUT INSPECTION PWF, kkl/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY u.� DATE <br /> CALL FOR A, INSPECTIONiPRIOR TO GROUTING AND FINAL INSPEC ON. <br /> . -E H 1426 7/72 1M <br />