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 Permit No. � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> I (Complete In Triplicate) 2 _ 041O <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 /> .0 23 E�7 L_Z44 f.%c -4,4_- <br /> JOB ADDRESS/LQCATION � ' <br /> ENSUS TRACT _ <br /> Owner's Nance ` <br /> Phone „�j-/ <br /> Address <br /> City <br /> Contractor's Name License # 0 7� Phone ~sy� <br /> oc23 <br /> TYPE OF WORK (Check) : NEW WELL / DEEPENV/ /RECONDITION /_/ DESTRUCTION /? <br /> Other /? <br /> 14STALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC �TANK SEWER LINES PIT PRIVY W <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER M t <br /> INTENDED USE TYPE OF WELL • CONSTRUCTION SPECIFICATIONS <br /> Industrial ; K Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing ,. <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Jf?- _, meq._ <br /> -•--�- g Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> " Other Other Information <br /> PUMP INSTALLATION: Contractor , <br /> Type of Pump ` <br /> t# H.P, <br /> PUMP REPLACEMENT: / / State Work Done - T'j- i PU <br /> PUMP REPAIR: / / State Work Done f <br />-- -- ' '-w- -, - - r s,. I <br /> ESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply withlall 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 /> d <br /> SIGNED - <br /> TITLE QI ` <br /> (DRAW PLOT PLAN ON REVERSE 'SIDE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> � r <br /> APPLICATION ACCEPTED BY DATE y �� <br /> ADDITIONAL COMMENTS: <br /> PHASE I ROUT INSPECTION P I NAL INSPECTION # <br /> INSPECTION BY _ DATE INSP DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> EH 1426 <br /> A 7/72 1M <br />