Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> �. <br /> FOR OFFICE U E: 1601. E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 ` <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> I Per it No. <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued J- -2-q--_71 <br /> (Complete In Triplicate) <br /> Application is hereby madelto 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 Joaqu# <br /> County' Ordinance No. '1862 and the, Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCA TION `f'� / D CENSUS TRACT <br /> t-, <br /> Owner's Name <br /> Phone <br /> Address r _ <br /> c��c--- city <br /> Contractor's Name j A!"License #.AA111 &'4Phone .. <br /> i Via{ <br /> TYPE OF WORK (Check) : NEW WELL /-7 DEEPEN /_/ RECONDITION /7 DESTRUCTION /-' <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> C <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 /> t Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing all <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> i <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. s <br /> PUMP REPLACEMENT: /j�/� State Work Done <br /> PUMP REPAIR: /% State Work Done <br /> i ,pESTRUCTION OF WELL: Well :Diameter <br /> _. ." Approximate Depth <br /> Describe Material and Procedure N <br /> I � <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 iaell and notify them before putting the well in use. The above <br /> information is true t . best of my knowledge and belief. <br /> SIGNED <br /> TITLE` <br /> {DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> ( APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS \II /FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY - , DATE <br /> i CALL FOR A GROUT INSPECTION PRIOR, TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 <br />