Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> v U A/ Telephone: {209} 465-67$1 <br /> \ICATION FOR WELL CONSTRUCTION: OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <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. 1$62 and the Rules and Regulations of the San Joaquin Local Health District. <br /> srx N <br /> JOB ADDRESS/LOCATION ) Gly . V CENSUS TRACT <br /> Owner's Name /L L �,C O Phone <br /> Address [\ z-P C-P LZ City <br /> Contractor's Name License 11/,:Q h.'hone <br /> TYPE OF WORK (Check): NEW WELL Aq DEEPEN / / RECONDITION /7 DESTRUCTION /-7 <br /> PUMP INSTALLATION )< PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other <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 l <br /> industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private -- Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing _ SjDaI-1 <br /> Irrigation Gravel Pack Depth of Grout Seal �� amD <br /> Other Rotary Type of Grout /! RMI <br /> Other Other Information I-L <br /> PUMP INSTALLATION: Contractor G f-= b4C C" <br /> Type of Pump t1Mt- • H.P. <br /> PUMP REPLACEMENT: . /-7 State Work Done , �� <br /> PUMP REPAIR: / / State Work Done <br /> .DESTRUCTION 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 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 /> 5 <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEP64TIAENT USE ONLY <br /> PRASE I _ <br /> APPLICATION ACCF U.n BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE, III/FINAJ, INSPECTION <br /> INSPECTION BY DATE INSPECTION BY -O SAT <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> F E H 1426 4/72 1M <br />