Laserfiche WebLink
lo SAN JOAQUIN LOCAL HFALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 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 6-1Y '- <br /> (Complete In Triplicate) <br /> Application � s/here1iylmade '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 /> r, <br /> JOB ADDRESS/LOCATION aC <br /> 9.-777 v6-:. P/s4e4;A -6 a:.'CENSUS TRACT O e?-- 2.4 O -O y <br /> Owner's Name <br /> Phone , - __ <br /> Address ( .- <br /> -�! city <br /> Contractor's Name Q r License Phone -T <br /> TYPE OF WORK (Check) : NEW WELLDEEPEN / / RECONDITION [—/ DESTRUCTION /- <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /- <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY ,p <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 <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal '4 <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor N <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR; State Work Done <br /> 01 <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 R. ORT of the well and notify them before putting the well in use. The above <br /> information s ue to he best of my knowledge and belief. <br /> SIGNED <br /> Vul <br /> TITLE <br /> (DRAW PL T P AN ON REVERSE SIDE) <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ATE <br /> ADDITIONAL CO TS:_ <br /> PIftI PHA NSPECTION <br /> INSPECTION B ATE INSPECTION et <br /> F DATE <br /> CALL FOR SP TION PRIOR TO GROUTING AND FINAL .IN <br /> E H 142 4/72 1M <br />