Laserfiche WebLink
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 P"erTAt 'No.'3-�99/IfD <br /> THIS PERMIT EXPIRES i YEAR FROM DATE "ISSUED Date Issued Z x �-5 <br /> (Complete In Triplicate) �"T <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 trade 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"'Name Phone " <br /> Address .fi✓ �c-y:.�/� cit- <br /> Contractor's <br /> it c� <br /> y <br /> Contractor's Name VL �cC��,.� License # " Phone <br /> zz <br /> TY.PE_OF_WORK (Check)-:.,ANEW:WELL/�/a �,DEEP.EN. /- / RECONDITION F7. ..DESTRUCTION <br /> PUMP INSTALLATION / PUMP REPAIR "/ /� UMP PLAC NT IZ7 <br /> Other <br /> T. <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 t+,, <br /> Domestic/private Drilled Dia. of Well Casing ! r <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal ; <br /> Other Rotary Type of Grout a <br /> Other Other Information <br /> .PUMP INSTALLATION: Contractor , -� <br /> Type o f Pump amu. H.P. /j 0 <br /> -PUMP REPLACEMENT: / / State Work Done <br /> .PUMP REPAIR: / / State Work Done <br /> DESTRUCTION,70F 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 /> information is true to the beUff knowledge and belief. <br /> SIGNED `z-- TITLE <br /> (DRAW PLOT. PLAN ON REVERSE SIDE <br /> FA DEP NT USE ONLY <br /> -PHASE I <br /> ,APPLICATION ACCEPT gyz onz DATE I'� 0 - -� <br /> .ADDITIONAL COMMENTS: <br /> PRASE II GROUT INSPECTION PHAS I/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 22 —/� <br /> 0 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING=AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />