Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH 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.L g6 0 <br />Date Issued <br />THIS PERMIT EXPIRES 1.YEAR FROM DATE ISSUED $�� <br />-7� <br />Application is hereby made to the San Joaquin Complete <br />uinLocal Health District for a permit to construct <br />and/or install the work herein described. This application is made in compliance with San Joaquin <br />County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br />JOB ADDRESS /LOCATION <br />eln _ CENSUS TRACT <br />Owner's Name <br />Address <br />Contract <br />Phone <br />City f <br />LIz.--I <br />Phone���� <br />TYPE OF WORK (Check) : NEW WELL IU--MPEN /"7 RECONDITION /_% DESTRUCTION /-'% <br />AL <br />PUMP INSTLATION plp REPAIR PUMP REPLACEMENT /% <br />/ <br />Other / — <br />TO <br />INTENDED USE <br />Industrial <br />—.�Omestic/private <br />Domestic/public <br />Irrigation <br />Other <br />anriiv iaN4 g-d� SE <br />SEWAGE DISPOSAL -FIELD <br />TYPE <br />FZK Julnbs PIT PRIVY <br />CESSPOOL/SEEPAGE PIT OTHER <br />ale Tool <br />Drilled <br />Driven <br />Gravel Pack <br />Rotary <br />Other <br />PUMP INSTALLATION: Contractor <br />Type of Pum <br />PUMP REPLACEMENT: <br />�-uNa KUUTIUN SPECIFICATIONS <br />Dia. of Well Excavation 4-54 <br />Dia, of Well Casing I <br />Gauge of Casing <br />Depth of Grout Seal <br />Type of Grout <br />Other Information <br />f-1 State Work Done <br />PUMP REPAIR: / % State Work Done <br />,DESTRUCTION OF WELL: Well Diameter <br />Describe Material and Procedure Approximate Depth <br />I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District C <br />and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br />after completion of my work on a new well. I will furnish the San Joaquin Local Health District a <br />WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br />information is true to the best of my knowledge and belief. <br />SIGNED --- TITL$ <br />PHASE I <br />APPLICATION ACCEPTED <br />ADDITIONAL COMMENTS: <br />INSPECTION BY <br />CALL FOR A GROUT INSPECTION PRIOR TO <br />E H 1426 <br />E <br />INSPECTION <br />AND FINAL INSPECTION. <br />DATE Z 1? / ( i <br />i <br />A <br />7/72 1M <br />1 <br />