Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Z Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 73 <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued. <br /> A lic (Complete In Triplicate) #23pp ation 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 /> Coun_ty:Ordinsnce. No.. 18.62 and the. Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION i <br /> CENSUS TRACT 20{0- hGOr17 <br /> Owner's Name Phone <br /> Address 741 f5u <br /> city <br /> Contractor's Name Q,� v -- ��6 - ,6v° b <br /> License # 1�ia .� Phone <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN /_/ RECONDITION /—/ DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR /—/ PUMP REPLACEMENT /—T <br /> Other / / — <br /> C <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 m <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 H.P. i <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: f / State Work Done <br /> ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> t <br /> a <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 INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />