Laserfiche WebLink
(J' SAN JOAQUIN LOCAL HEALTH DISTRICT ` <br /> R OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. j. <br /> THIS PERMIT `EXPIRES 1 YEAR FROM DATE ISSUED Date Issued_5-,h0/7_3 <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 a CENSUS TRACT <br /> Owner's Name •G a Phone <br /> Address City <br /> Contractor's Name License <br /> A <br /> TYPE OF WORK (Check): NEW WELL X DEEPEN / / RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <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 <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private �&. Drilled Dia, of Well Casing , <br /> Domestic/public Driven Gauge of Casing r <br /> Irrigation Gravel Pack Depth of Grout Seal ? "� <br /> Other Rotary Type of Grout or <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / 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 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 /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE g-sv-7J' INSPECTION BYeV 2 DATE 7 j <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 >7 9s 7/72 1M [� j <br />