Laserfiche WebLink
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 PERMIT Permit No. ��,L�h <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued , -, ZV s- <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 <br /> CENSUS TRACT <br /> Owner's Name ( / ��� y L <br /> Phone <br /> Address 1-9. <br /> � <br /> city <br /> f � f <br /> Contractor's Name °�. G ".� �,`� T.-� License # Phone <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /J RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION / / piJMP REPAIR / / PUMP REPLACEMENT /7T <br /> Other /% -- -` <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT pglVy �� <br /> SEWAGE DISPOSAL, FIELD CESSPOOL/SEEPAGE PIT OTHER c 1 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <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 Gravel Pack Depth of Grout Seal <br /> Other _ Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> -E <br /> H.P. — <br /> PUMP REPLACEMENT: / State Work Done <br /> PUMP REPAIR: f <br /> State Work Done <br /> ESTRUCTION 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 Joaquin Local Health District <br /> and the State of California pertaining to or regulating well constrction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Jouaquin 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 best of my knowledge and belief. <br /> SIGNED �� <br /> - if TITLEf =1" <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P S I FINAL INSPEC IO <br /> INSPECTION BY�� _ DATE INSPECTION BY DATE <br /> CALL FOR A GRO INSPECTION PRIOR TO GROUTING AND FINAL INS ON. <br /> E A 1426 . <br /> 7/72 1M <br />