Laserfiche WebLink
Y K <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0�.;01'FICI US1.;_, 1601 E. Hazelton Ave. , Stockton,° Calif. <br /> — Telephone: (209) 466-6781 <br /> ` r APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 75�� <br /> 7s-s�!" <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date lssued�a <br /> (Complete In Triplicate) t <br /> Application is hereby made. to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work <br /> 62eandnthe$Rules and Regulatlonsapplication <br /> the Sanmade <br /> Joaqui.ncompliance <br /> San Joaquin , <br /> HealthDistrict. <br /> County Ordinance Ido. 18 18 . <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> Phone . . �" <br /> Owner's Name <br /> City �wl e ; <br /> Address e. ce. T, 1 <br /> Contractor`s Nauie <br /> License'4Phone -! <br /> _j <br /> TYPE OF WORK (Check): NEW WELL DEEPEN / -/ RECONDITION_/_/ DESTRUCTION / T <br /> PUMP INSTALLATION / PUMP REPAIR'/ / ,.,PUMP REPLACEMENT I�T <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWERrLINES PIT PRIVY <br /> + � SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER '4) <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> "' , <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private , Drilled Dia. of Well Casing h <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation_ _:Gravel Pack Depth of Grout Seal <br /> Other _ Rotary Type of Grout 4 0 OR I <br /> Other Other Information ' <br /> PLNI1P IN5TALLATION: Contractor + .a- % <br /> Type of Pump H.P. - <br /> PUMP REPLACEMENT: { / State Work Done <br /> f PUMP UPAIR: - / State Work Done <br /> ,DFRTRUCTION 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 /> i WELL DRILLERS REPORT he well and notify them before putting the well in use. The above <br /> information is tr to the best of my knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> FO -DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED .BY DATE <br /> ADDITIONAL COMMENTS: p <br /> ,. P E II ,GR T INSPEC P S I/F AL INSPECTION <br /> INSPECTION BY DATE P C I DA <br /> CAI-�-F'OR� A-GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPEC ION. <br /> # 5/73 <br />