Laserfiche WebLink
_ SAN JOAQUIN LOCAL UEALTH DISTRICT <br /> FOR OFFICE USE: - 1601 E. Hazelton Ave. , Stockton-, Calif. - j <br /> Telephone: (209) 466--6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT, Permit No. -ZZ.1 5 <br /> i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued Z-2-y- <br /> ( <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 /> JOB ADDRESS/LOCATION , CENSUS TRACT <br /> Owner.'s Name _ � G7 Phone <br /> Address z 2 J 51 Cit <br /> Contractor's Name ` License # Phone r <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/ / RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR /PUMPREPLACEMENT / <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 I}rilled 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 tA <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Doneas•� �� Ea��CE c.,,'��j G <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 E <br /> information is true to the best of my-knowledge and belief. <br /> S <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) r <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �/4/ DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE IL GROUT INSPECTION P II ./FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY9DATE 7� <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M �C�' <br />