Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 601. E. Hazelron. AVe. , Stockton, Calif. <br /> Telephone::. , (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS El� .PERMIT EXPIRES `1' YEAR FROM DATr `ISSUED Date Issued a l�"7 <br /> (Cotriplete In Triplicate) <br /> a' permitApplication 'is hereby made- to the; San Joaquin <br /> Locall e-A istmade inrcompliancetwithnSanuJoaquin <br /> This and/or install the work herein described. pp <br /> County ordinance• No. .1862 and the Rules and <br /> e!uF �� }06�Y�i/in Local Health District. <br /> ( CENSUS TRACT <br /> JOB ADDRESS/LOCATION <br /> Phone <br /> Owner's Name+ Geo / 1 rS7G J <br /> t�0 <br /> City <br /> Address <br /> T License # 3 -'phone <br /> Contractor's Name , <br />' TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION /_/ DESTRUCTION f7 <br /> I PUMP INSTALLATION / / PIMP REPAIR y PUMP REPLACEMENT /— <br /> � Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> I INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> F Industrial Cable Tool Dia., of Well Excavation <br /> Drilled Dia. of Well Casing <br /> Domestic/private Driven Gauge of Casing Q <br /> C Vu Domestic/public <br /> T Irrigation � Gravel Pack Depth of rout Seal <br /> Other RotaryType of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor C�� H.P. a <br /> Type of Pump <br /> 1 PUMP REPLACEMENT: / / State Work Done <br /> 111� of <br /> State Work Done D�e1�1 ' <br /> I II <br /> PUMP REPAIR: �/ ' <br /> ,DESTRUCTION OF WELL: Well Diameter <br /> 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 /> ill furnish the San Joaquin Local Health District a <br /> after completion of my work on a new well, I w <br /> WELL DRILLERS REPORT of the well and notify them before putting the well use. The above <br /> information is true to the best of my knowled e an elief <br /> SIGNED <br /> (B P T PL N REVE SIDE) <br /> DEPARTMENT USE ONLX / <br /> PHASE I / ,( DATE ' <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: - �pHAS II /FINAL IN N <br /> PHASE II GROUT INSPECTION INSPECTION BZ <br /> INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL. INSPECTION. 4/72 IM <br /> i.. E H 1426 c <br /> w ;� <br />