Laserfiche WebLink
- <br /> k> :+""" �" SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F R OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 ) <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. - �z <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date 'Issued q=a__23 <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 &M g6WkCENSUS TRACT <br /> Owner's Name Phone <br /> Address _ City ,r,� �... <br /> Contractors Name <br /> License # /fid 7ZV Phone <br /> a <br /> f <br /> TYPE OF. WORK_(Check): L NEW WELL DEEPEN /_� RECONDITION /_7�.DESTRUCTION.-/_7 <br /> fi PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /� <br /> �- Other <br /> DISTANCE TO NEAREST: SEPTIC TANK =o SEWER LINES PIT PRIVY <br /> i± SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> k <br /> { INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial _ _- Cable Tool Dia: of Well Excavation <br /> -`. Domestic/private Drilled Dia. of Well Casing " c <br /> Domestic/public Driven -Gauge of Casing �?J <br /> Irrigation Gravel Pack r Depth of�Gro'ut Seal <br /> Other Rotary. Typeiof Grout <br /> Other Other Information <br /> E PUMP INSTALLATION Contractor <br /> „Type of Pump H.P. <br /> PUMPIREPLACEMENT: / / State Work Done <br /> PUMP :REPAIR: / / State Work Done '} <br /> 5 <br /> RUCTION Approximate.-Depth..- <br /> ,DEST - <br /> Describe' Material and Procedure <br /> f: <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 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 tothe best of my knowledge and belief. <br /> SIGNED TITLE <br /> ' (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> I <br /> PHASE I � ,p DATE � /..� <br /> APPLICATION ACCEPTED BY C .l <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE L <br /> CALL FOR A GROUT INSPECTION ,PRIOR TO GROUTING AND FINAL INSPECTION. <br /> K �H,1426 - _ 7/72 1M <br />