Laserfiche WebLink
SAN JQAQUJN-LOCAL TIEALTH DISTRICT <br /> FOR OFFICE .USE: 1.601 E. Hazelton Avh;l, <br /> Stockton, Calif. <br /> Telephone: (209) 466-6781 t� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No <br /> F 73-6i�� <br /> THIS PERMIT EXPIRES 1 YEAR-FROM DATE ISSUED Date Issued <br /> j� <br /> . (Complete In Triplicate) <br /> Application is, hereby -made,to theSan 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 /> JOB ADDRESSLOCATION . �'; � . f � <br /> l �• `'' it r r i �' '' CENSUS TRACT ' <br /> Owner`s Name.' - � ' Phone ' <br /> Address r Ems, . � �"".`., E <br /> '� City = ',a e. t <br /> Contractor's Name :y ;: y-` License Phone ` <br />"TYPE OF WORK(C-hheeck) : NEWE <br /> LL <br /> DEEP-N ' ;tECONI3ZT20_J_�""DESTRIICfi N/? <br /> 7 <br /> . PUMP .INSTALLATION / / PUMP. REPAIR '/ / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK ,oil"" SEWER LINES , , PIT PRIVY . <br /> s SEWAGE'DISPOSAL FIELD "z:-VICESSPOOL/SEEPAGE PIT OTHER <br /> l <br /> INTENDED USE <br /> TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia."_„ Well Excavation <br /> Z // <br /> - <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing ,� <br /> Irrigation �V'_„Gravel Pack Depth of Grout Sear E <br /> Other vO' Rotas - <br /> Y Type of Grout <br /> Other Other Information - <br /> PUMP INSTALLATION: <br /> nformation —PUMP .INSTALLATION: Contractor <br /> Type of Pump s: - _ Ar F H.P. a t <br /> PUMP REPLACEMENT: / / State Work Done <br /> i <br /> ../ <br /> PUMP REPAIR: / State Work Done + <br /> .]ESTRUCTION OF WELL: Well Diameters <br /> 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 /> -" ; <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) i <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> fAP� PLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE 4 <br /> PHASE Il GROUT INSPECTION PHASE II/FINAL INSPECTION <br /> INSPECTION BY '" DATE : INSPECTION BY DATE <br /> CALL FOR A GROUT-INSPECTION_PRIOR TO' GROUTING AND FINAL INS ION, <br /> E H 3426 <br /> 4/72 IM <br />