Laserfiche WebLink
(1 `- 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. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED, . Date Issued <br /> (Complete In Triplicate) J <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 /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIO CENSUS TRACT S 7 <br /> Owner's Name --3 e20 1 <br /> Phone <br /> Address City <br /> Contractor's Name License A2Z7je&phone <br /> gK <br /> TYPE OF WORK (Check): NEW WELLDEEPEN /% RECONDITION /7 DESTRUCTION /7 <br /> PUMP INST TION / / PUMP REPAIR / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK I SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD /5D/CESSPOOL/SEEPAGE PIT �' OTHER ,A <br /> INTENDED USE TYPE OF ELL � - CONSTRUCTION SPECIFICATIONS / W <br /> Industrial Cable Tool Dia. of Well Excavation <br /> l-�Omeatic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout p <br /> Other Other Information - <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / J State Work Done <br /> PUMP REPAIR: / / State Work Done <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,,l 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 ie rue to the bes of my knowledge and belief.` - TITLE DLJ/twc- <br /> (D PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY9� DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY 4Z DATE 2--(-73 INSPECTION BY DATE -,e-73 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. ocz� <br /> E H 1426 7/72 1M <br />