Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR EF'ICE USE: � <br /> 1i'' 160 . E. Hazelton Ave. .' <br /> ve, Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.T3-5�,2,�r 4) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date issued 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 Joaquir <br /> County Ordinance No. 1862 And the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 73. COM 12- CENSUS TRACT S- <br /> Owner's Name (� 11?�i j Phone 3 J- Z �0 <br /> Address n4 City G }LZ? <br /> Contractor's Name 1 N( _ ___� License # Phone <br /> TYPE OF WORK (Check): NEW WELL DEEPEN / / TRECONDITION DESTRUCTION /�" <br /> PUMP INSTLATION PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> AL <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK _,_ SEWER LINES PIT PRIVY �� <br /> SEWAGE DISPOSAL FIELD 0� CESSPOOL/SEEPAGE PIT/ OTHER IV— . <br /> k <br /> INTENDED USE TYPE OF WELL. CONSTRUCTION SPECIFICATIONS <br /> ::ZIndustrial - able Tool Dia. of Well Excavation <br /> Domestic/private gilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing r <br /> Irrigation -ice Gravel Pack Depth of Grout Seal <br /> Other K' Rotary Type of Grout <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 /> .RESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> .1 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, 1 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 /> F FOR DEP T USE ONLY <br /> PHASE I <br /> ( APPLICATION ACCEPTED DATE <br /> ADDITIONAL COMMENTS: <br /> P I GROUT INSPECTIO P III NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION,E),&e DATE -2--:Z-f- <br /> 31� <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> { <br /> E H 1426, 7/72 IM <br />