Laserfiche WebLink
SAN AQUIN LOCAL HEALTH DISTRICT f <br /> FOR OFFICE USE: / 1601 E. Hazelton Ave. , Stockton, Calif. <br /> I/ Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) Q <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct uct <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 -; /.r71 E CENSUS TRACT �7 <br /> Owner's Name �CL— Phone " <br /> Address /r'- City 114 Te' <br /> Contractor's Name Q .- License # Phone <br /> TYPE OF WORK (Check) : NEW WELLK DEEPEN '/-7 RECONDITION /_7 DESTRUCTION /-7 <br /> PUMP INSTAL ATION / / 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 /> Domestic/private �Drilled Dia. of Well Casing g2r <br /> Domestic/public Driven Gauge of Casing f� <br /> Irrigation Gravel Pack Depth of Grout Seal -- <br /> Other Rotary Type of Grout }}I � �1r� C/ `� i► <br /> Other Other Information C <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br />.- PUMP-REPAIR: / / 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 <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> OR DEP T USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED ..r <br /> DATEZO��� <br /> ADDITIONAL COMMENTS: <br /> I OUT INSPECTION P II F AL INSPECTION <br /> INSPECTION BY -- DATE —f_ INSPECX121_b E <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />