Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,Z,� -S3 P <br /> THIS PERMIT_ EXPIRES l YEAR FROM DATE ISSUED Date Issued <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. 18/62 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIONCENSUS TRACT <br /> - <br /> 2 �_ �iG�1�/ II ' Ir I1--, Q c3 <br /> `7 <br /> Owner's Name 12 L i1;7 Phone ��- l$2 <br /> Address if TA — --- - City <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check); NEW WELL / / DEEPEN /_/ RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /7 <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 /> A-9Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation � Gravel Pack Depth of Grout Seal Q ' <br /> Other Rotary Type of Grout _ <br /> — Other Other Information <br /> PUMP INSTALLATION,. G <br /> Type of Pu r l H.P. <br /> PUMP REPLACEMENT: / / State Work Done , <br /> PUMP REPAIR: / / State Work Done <br /> .pESTRUCTION 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 /> I � <br /> SIGNED �. TITLE <br /> (DRAW PLOT PL ERSE SIDE <br /> FOR DEPARMNTUSE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE , <br /> J ADDITIONAL COMMENTS.- - <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY,ZQ & DATE /O <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 IM <br />