Laserfiche WebLink
n , 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 PERMITPermit No. ,P'S-- <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. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION Jou CENSUS TRACT <br /> Owner's Name NA Phone <br /> Address 2-3 - City �zri pec �a <br /> Contractor's Name C.� /oC . -� �� r �'� �` License # PhoneC! —U .r <br /> TYPE OF WORK (Check): NEW WELL / DEEPEN /_� RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTLATION / / PUMP REPAIR / / PUMP PLAC NT /? <br /> AL <br /> ..Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY V' <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS V <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 T 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. f <br /> PUMP REPLACEMENT: / / 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 3oaquin 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 o the best of my knowledge and belief. <br /> SIGNED TITLE G� <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> zz <br /> FOR DEPARTMENT USE ONLY <br /> ' PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P S I FINAL INSPECTION <br /> } INSPECTION BY <br /> INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSP ION. <br /> E H 1426 7/72 1M <br />