Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466 .6.781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7Z- Icr-� 3 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �Z <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. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> ruse 1 7.-10 t - X70-mss <br /> JOB ADDRESS/LOCATION' �.4' -1 .j . CENSUS TRACT . <br /> Owner's Name =p Phone <br /> Address �a G- `` / - - - - City . <br /> s <br /> Contractor's Name ( � �� / _ � ,,.� � License # Phone c4.r <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION /-7 DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR // PUMP REPLACEMENT /- <br /> Other <br /> T m <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> t <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS S <br /> Industrial Cable Tool Dia, of Well Excavation t1 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal n <br /> Other Rotary Type of Grout i <br /> Other Other Information i <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done - <br /> -�c67 <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 Nw L, 6 A, TITLE �f <br /> (DRAW PLOT LAN ON REVERSE SIDE <br /> ..FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: OVA <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO -GROUTING AND FINAL INSPECTION. <br /> E H 1426 _ . 7/72 1M <br />