Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH? DISTRICT R <br /> FOR OFFICE USE: r 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466•-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 Z— lo/ L <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued T/ <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 Ryles and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT S <br /> Owner's Name Phone <br /> Address 5)9r-7s City <br /> Contractor's Name zZf Aej,f F' rV J � i ` o'-�n; i ,r3 License #f! 1 Phone , - b 143 <br /> TYPE OF WORK (Check) : NEW WELL% EEPEN / / RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP 'INSTALLATION /�/ 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 J <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge 'of Casing <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 /> s <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> .pESTRUCTION 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/&P TITLE <br /> T (DRAW PLOT PLAN ON REVERSE SIDE <br /> M FOR DEPARTMENT USE ONLY <br /> PHASE I j+, <br /> APPLICATION ACCEPTED BY- <br /> DATE .� �' r"' - <br /> ADDITIONAL COMMENTS: F' <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY w DATES JF-9Z, INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M c.,-1-25 <br />