Laserfiche WebLink
/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICEiUSE: 1601 E. Hazelton Ave. , Stockton, Calif, <br /> ' Telephone: (209) 466-6781 <br /> I APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 3- S <br /> i <br /> - THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED .Date Issued to_-z _Jq <br /> Applicationt'is hereby made'to the San <br /> (Complete In <br /> for a <br /> permit <br /> and/or install the work herein described. This application is made in compl ancetwithnct SanuJoaqui <br /> County Ordinance No. 1862 and the Rules ,and Regulations of the San Joaquin Local <br /> , � u1Health <br /> Di-st—ri- <br /> ct. <br /> JOB ADDRESS/LOCATION CENSUS TRACT rOwner's Namee <br /> Phone a4&— hg-&r <br /> Address city <br /> Contractor's Name a License IV.?Z [� <br /> I. �s--,�� Phone <br /> i <br /> TYPE OF WORKI (Check): NEW WELL /—j DEEPEN /_% RECONDITION /-7 DESTRUCTION /-] <br /> � PUMPiIINSTALLATION PUMP REPAIR <br /> Other J / PUMP REPLACEMENT <br /> Paste <br /> DISTANCE TO NEAREST SEPTIC TANK SEWER LI S PIT PRIVY <br /> -I S WAGE DISPOSAL FIELD`,I � CES POOL/SEEPAGE PIT OTHER <br /> INTENDED®E A�-H1 -a-�1[az� D� <br /> 'EVE OF WELL �� CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool v Dia, of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing V.t <br /> Domestic/public Driven Gauge of Casing .�. <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary `a <br /> Type of Grout 0 <br /> Other Other Information <br /> PUMP INSTALLATION: ` Contractor <br /> _ ....�TYpe; of PumpH.P. 3 <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: 'I / / State Work Done <br /> ,RESTRUCTION OF WELL: Well Diameter <br /> `�. 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 DRILLERSjPEPORT of the well and notify them before putting the well in use. The above <br /> _information is true to the b' t of my knowledge and belief, <br /> r <br /> SIGNED , TITLE <br /> ' DRAW PLOT PLAN ON REVERSE SIDE) <br /> j <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY „„� DATE /O'/�- '7�� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY,: DATE INSPECTION BYi'/J DATE <br /> /o •z v•73 <br /> CALL FOR A 'CROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 If 7/72 1M <br />