Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT # H O <br /> FOR OFFICE-USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 3 l07 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 73 _ y jz <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued g- 14-�/, <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 Joaq, <br /> County Ordinance No. 1862 and the Ruler a �eaujations of the San Joaquin Local Health District <br /> lr <br /> �j v k `T <br /> JOB ARB&9/LOCATION - —� — CENSUS TRACT <br /> Owner's Name f ) Phone <br /> Address <br /> Cit ljjr <br /> Contractor's Name �S / / i'S S License g;bez PhoneL�� <br /> TYPE"OF WORK (Check) : NEW WELL 1 DEEPEN /_ - RECONDITION /-7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK _ ;J tSEWE/ ��LIN��ES z f PIT PRIVY q � <br /> SEWAGE DISPOSAL FIELD "'�/i1 CESSTe6L/SEEPAGE PIT/� / OTHER /U d'0 <br /> INTENDED USE TYPE OF-WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation le5l ' <br /> Domestic/private Drilled Dia. of Well Casing i/ C <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 y' 2 /p <br /> Type of Pump H.P. <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 e <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is tr!!p to the best of my knowledge and belief. f <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE> <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I (/ <br /> APPLICATION ACCEPTED BY DATE O 3 -3 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT IN PECTION PHA II FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE /Q <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECT ON. W-� <br />