Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> iOF ZFFICE USE: 1601 E. Hazelton Ave.; Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> 77 !. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �/,/- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 24 <br /> k <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 /> and Regulations of the San Joaquin. Local: Health District. <br /> County Ordinance No. 1812 and the Rules � <br /> CENSUS TRACT " <br /> JOB ADDRESS/LOCATION �✓7� � J `" - <br /> Phone <br /> Owner's Name' v l <br /> Address w 1[ 4C,: City <br /> License '��;J/.ctcl�S Phone ��tXi . <br /> Contractor's Name . <br /> TYPE OF WORK (Check) : NEW WELL 'f, DEEPEN _I RECONDITION_/ / DESTRUCTION ,/ • <br /> PUMP INSTLATION PUMP REPAIR'/REPAIR'/ I PUMP REPLACEMENT 1_7 <br /> AL <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK v_'" SEWER LINES.-) � PIT PRIVY <br /> SEWAGE DISPOSAL FIELD, ` CESSPOOL/SEEPAGE PIT OTHER <br /> E INTENDED USE TYPE OF WELL- CONSTRUCTION SPECIFICATIONS <br /> Casing Industrial � (�, Cable Tool Dia. of Well Excavation <br /> Domestic/,private Drilled r Dia. of WCasing <br /> Domestic/public Driven Gauge of CCasing /U . <br /> Irrigation Gravel. Pack Depth of Grout Seal <br /> Other Rotary_- Type of Grout <br /> f--- - ' Other' Other Information ' <br /> PUMP ,INSTALLATION: Contractor <br /> T• y P Type of Pump H.P. JD <br /> w <br /> PUMP REPLACEMENT: / / State Work Dane <br /> PUMP 'tEPAIR: %/—State Work Done <br /> ,DF-ZTRUCTION OF WELL: Well Diameter F 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 /> k and the State of California pertaining to or -regulating well ''construction. Within FIFTEEN DAYS <br /> f after completion of my work on a new well, I will furnish the San.Joaquin Local Health District a <br /> i CELL 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 TITLE <br /> (DRAW PLOT: PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE ;2 <br /> APPLICATION ACCEPTEDyB -- . <br /> ADDITIONAL:ICOMMEN TS: <br /> PHASE II GROUT INSPECTION /l PHASE. III/FINAL INSPECTION� 7 <br /> INSPECTION BY DATE INSPECTION BY _ IDATE - 7 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> 5/73 <br /> E H 1426 -''' <br />