Laserfiche WebLink
Com° <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> .FOR OFFICE USE: .1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.�� - Ga <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED . Date Issued <br /> (Complete In Triplicate) <br /> Applic.ation' 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 /> , <br /> u z ocz r.� .r T 0�3 <br /> JOB sCADDE,SS/LOCATI4r /7 .ON — CENSUS TRACT <br /> Owner's Name 6 �B a q, Phone <br /> Address If 01 E Z City <br /> Contractors Name License # gPhone <br /> TYPE OI' WORK (Check) : NEW WELL / / DEEPEN J RECONDITION DESTRUCTION /-7AL <br /> PUMP INSTLATION / f PUMP REPAIR �M_PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY 6' <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER i <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 Dane V� <br /> PUMP REPAIR: State Work D s <br /> i <br /> .DESTRUCTION OF WELL: Well Diameter Approximate Depth wf <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District I <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 /> SIGNEDTITLE <br /> r ' - - <br /> (DRAW PLOT PLAN ON REVERSE SIDLE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE ,II GROUT INSPECTION PHASE IIT/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE - -73 . <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 IM <br />