Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 7z- <br /> APPLICATION <br /> z <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -7Z__101W <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 'j - - 7y' <br /> TUur (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 CENSUS TRACT i <br /> 4 <br /> Owner's Name Phone <br /> Addresseu==c Cit��y <br /> Contractor's Name 4-,Sv A- � License !�� �t� Phone , _ qy <br /> TYPE OF WORK (Check) : NEW WELL /;F�_ DEEPEN RECONDITION /7 DESTRUCTION /`7 <br /> G PUMP INSTALLATION /4--_-PUMP REPAIR / / PUMP REPLACEMENT /7 e <br /> Other <br /> I <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY ([51 p <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> r INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �j <br /> Industrial Cable Tool Dia. of Well Excavation � � _J <br /> __ .. Domestic/private Drilled Dia. of Well Casing 5„ / �i <br /> Domestic/public Driven Gauge of Casing ft <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other <br /> �a Rotary Type of Grout _ git__� )" <br />! Other Other Information y-�, ,� � <br /> R <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump .11-0—= H.P. �-- <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ,DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i <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 th my knowledge and belief. <br /> r <br />' SIGNED TITLE { <br /> RAW PLOT PLAN ON REVERSE SID { <br /> FOR DEPARTMENT USE ONLY <br /> -7 I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE INSPECTION <br /> INSPECTION BY DATE —3— /�_. INSPECTION BY DATE -2 — <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPEtN'� <br /> E H 1426 7/72 1M <br />