Laserfiche WebLink
i <br /> TJ SAN JOAQUIN LOCAL .HEALTH DISTRICT <br /> FOR OFFICE SE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> E APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -�� �. <br /> f <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued k-Z <br /> (Complete In Triplicate) W*) <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 CENSUS TRACT <br /> Owner's Name / <br /> Phonef2rr�_-S <br /> Address City <br /> Contractor's Name License #! L,? Phone <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN /_ RECONDITION /_/ DESTRUCTION /-7AL /—/ —PUMP <br /> -- - ! <br /> PUMP 'INSTLATION / / 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 <br /> Industrial { Cable Tool Dia, of Well Excavation 00 <br /> Domestic/privateNO <br /> Drilled Dia, of Well` Casing <br /> Domestic/public I Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information, <br /> k <br />+' PUMP INSTALLATION: Contractor Q' <br /> k Type of Pump H.P. <br /> PUMP REPLACEMENT: / State Work Done .. <br /> I <br />+ PUMP REPAIR: / / State Work Done <br />; . ESTRUCT_I.ON OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> 1 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 /> SIGNED _ r; TITLEL"I,-1 M <br /> - <br /> (DRAW PLOT P ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> fAPPLICATION ACCEPTED BY DATE f' v <br /> ADDITIONAL COMMENTS: <br /> PHASI GROUT INSPECTION PHASE II/FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE 3 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL. INSPECTI . <br /> E H 1426 7/72 IMy <br />