Laserfiche WebLink
r « <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT W <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> ,E Telephone: (209) 466-6781 { <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> %2- <br /> THIS PERMIT EXPIRES 1 YEAR FROM-DATE ISSUER Date Issued; i�- '-72 <br /> (Complete in Triplicate) <br /> Application is hereby made tdathe San Joaquin 'Loca1 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, 18621and:�the Rules and Regulations of the San Joaquin Local Health District. ` <br /> JOB ADDRESS/LOCAT1- ' CENSUS TRACT _ - <br /> K <br /> Owner's Name. Phone <br /> Address i, City �c ' <br /> Contractor's Name P7 S � � Jf <br /> � License Phone 717 <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /7 RECONDITION /-7- DESTRUCTION /7 <br /> PUMP INST LAI?TION PUMP REPAIR / / PUMP REPLACEMENT /-7 _ <br /> Other • <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES � PIT PRIVY <br /> SEWAGE DISPOSALQLD CESSPOOL/SEEPAGE PIT OTHER as <br /> x INTENDED USE TYPE OF WELL V CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable ToolD`ia-: of Well Excavation---/ <br /> Domestic/private 1! >t� Drilled Dia Wel_.l-FCasing <br /> Domestic/public i! Driven Gauge of Casing Z <br /> Irrigation Gravel Pack Depth of Grout Seal ,,,4Z::;* <br /> Other Roiary Type..of' Grout ,p �ir� - <br /> f <br /> ,eOther Other_71n€ormation <br /> PUMP INSTALLATION: Contractor d .< <br /> Type/of Pump H.P. <br />�­PUMP REPLACEMENT: / `'`/ State Work Done , +' <br /> PUMP REPAIR: / ,/ State Work Done <br />; „DESTRUCTION- OFWELL_: Well Diameter ', Approximate Depth <br /> Describe Material and ,Procedure �. <br /> I hereby agree`to -complylwith all laws and regulations of the San Joaquin Local Health District <br /> and thg State_:of_Calif.ornia 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�putttirig the well in use. The above <br /> i <br />( information_ s true_.to the best of my knowledge- and'belief. <br /> SIGNED TITLE <br /> (DRAW PL PLAN ON REVERSE SIDE <br /> (_, ._ —FOR-DEPARTMENT USE ONLY <br /> PHASE I ���-y*.:- _.�.--� - :.. <br /> APPLICATION ACCEPTED BY I DATA <br /> ADDITIONAL COMMENTS: " A <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DTE ff <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> 7/72 1M <br /> E H 1426 ;i . <br />