Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7,5;--- <br /> THIS <br /> s=THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -r-S-- 7S-- <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 trade 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 -��Oa CENSUS TRACT <br /> Owner's Name Phone <br /> Address 00 Yo <br /> �1 city <br /> Contractor's Name al/d Zv ,p-r License #-Wd efb Phone A-7 <br /> u GG f 2 �--�- <br /> TYPE OF WORK (Check): NEW WELL /% DEEPEN /_% RECONDITION /_7 DESTRUCTION /-' <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT / <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER vl <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> -�-� Industrial Cable Tool Dia, of Well Excavation Q <br /> �L 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 .116 /rL, <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /L/s State Work Done <br /> PUMP REPAIR: /% State Work Done <br /> ,DESTRUCTION 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 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 TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> �} <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE- III/FINAL INSPECTIO <br /> INSPECTION BY N\ J11 r_ DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSP ON. <br /> E H 1426 7/72 IM <br />