Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (2'09)- 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,f2_1,4 r� <br /> THIS PERMIT EXPIRES 1 .YEAR FROM DATE ISSUED Date Issued <br /> (0 &4t 0,461( (Complete In Triplicate) $`3 _ 1&0 �-0 � <br /> Application is hereby m4de�to the San.Joaquin .Local Realth 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 <br /> Owner's Name UWk` Phone / <br /> Address ' b ul City C o <br /> Contractor's Name License # E d Phone ' <br /> TYPE OF WORK ;(Check) : NEW WELL/ DEEPEN /_7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR '/ / PUMP REPLACEMENT I7 ~� <br /> Other / / r10 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY `-P, <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial �_ Cable Tool Dia. of Well Excavation CC <br /> Domestic/private Drilled Dia. of Well Casing t 7 h`.CL G <br /> Domestic/public Driven Gauge of Casing g <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. <br /> PUMP REPLACEMENT: f / State Work Done <br /> r <br /> PUMP REPAIR: /_7 State Work Done <br /> .DESTRUCTION 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 D PART E ONLY -- - - <br /> PHASE I <br /> APPLICATION ACCEPTED BY j DATE It <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA III/F AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY AV7DATE Z <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTIOC <br /> E H 1426 4/72 1M <br />