Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE US . c 1601 E. Hazelton"Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6.781 <br /> 'PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No: �9?z, <br /> THIS PERMIV EXPIRES 1 `YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) ' <br /> Sari Joaquin Local Health District for a permit to construct <br /> Application is- hereby"made tojthe ° <br /> and/or install the work herein described. This application is made in compliance with San. Joaquin <br /> County Ordinance: No. 1862` and-ithe Rules and Regulati.ons' of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ✓ /} J4 CENSUS TRACT <br /> Owner's Nates'. y�� = ' N �EWy � �Phon b <br /> Address �l l -.• ✓ �`�'"\ s/ 1 <br /> City:.._ <br /> Contractor's Name 1,y: License #/ - Phone em I <br /> I <br /> TYPE OF -WORK (Check): NEW-WELL /% -DEEPEN / / RECONDTTrON'/77_DESTRUCTIOI3 / 7' LL - <br /> PUMP INSTALLATION / J PUMP REPAIR PUMP REPLACEMENT / <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY M <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> _ Industrial t Cable Tool Dia. of Well Excavation <br /> Domestic/private i Drilled. Dia. of Well Casing <br /> Domestic/public ;I Driven Gauge of Casing <br /> Irrigation G Gravel Pack Depth of Grout Seal <br /> Other ',I Rotary Type of Grout f <br /> ;1 Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: <br /> /-7 State Work Done <br /> IL <br />.PESTRUCTION O 4/-, L <br /> _F WELL: Well Diameter Approximate Depth r <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 ona 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 /> SIGNED 7� 7 <br /> �iln,w� �.� � TITLE <br /> (DRAW PL PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PRASE II GROUT INSiPECTION PHASEI i FINAL INSPECTIO <br /> INSPECTION BY DATE. INSPECTION BY] DATE <br /> CALL FOR A GROUT. INSPECTION,,PRIOR .TO. GROUTING AND FINAL INSPECTIOZ <br /> E H 1426 7/72 1M <br />