Laserfiche WebLink
i <br /> AN JOAQUIN LOCAL HEALTH DISTRICT <br /> VOR OFFICE USE: 1.641 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7�_12 p10 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �-�6 <br /> (Complete In Triplicate) -wo-Ce <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 /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Namer �r <br /> Phone ,aa �Address <br /> City U City <br /> Contractor's Name _ License 41/� ,&20Pbone&1 <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN /_/ RECONDITION /_7 DESTRUCTION /`7 N <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /_ <br /> Other <br /> V, , <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 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: /7 State Work Done <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 Districtl <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS Cl <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 lelTITLE <br /> !L= <br /> (DRAW PLOT PLAN ON REVERSE SI <,,v <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE�� <br /> ADDITIONAL COMMENTS: " <br /> PHASE II GROUT_ NSPECTION PHASE III IAL INSPE TION <br /> INSPECTION BY - DATE INSPECTION BY DAT - 7417 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />