Laserfiche WebLink
SAN JOAQUIN` LOCAL HEALTH DISTRICT <br /> FOR OF CE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is he'teby 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 :» ..., Phone 4/4> - ?Fsf <br /> ... <br /> Address me& a-�o City <br /> Contractor's Name License # AW24 PhoneF <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN /-7 RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / j PUMP REPAIR / / PUMP REPLACEMENT <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 OC Cable Tool Dia, of Well Excavation _ <br /> Domestic/private Drilled Dia. of Well Casing 11.0f. <br /> Domestic/public Driven Gauge of Casing z2- <br /> Irrigation Gravel Pack Depth of Grout Seal sa <br /> Other Rotary Type of Grout 0„.A,,r <br /> & Z AhMdA—AAA — Other Other Information <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 IL TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I <br /> FOR DEPARTMEN USE ONLY <br /> k <br /> �% <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE <br /> PHASE I I SPECTI N PHASE FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY <br /> CALL FOR ' UT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION.-� <br /> E H 1426 7/72 1M <br />