Laserfiche WebLink
S1"' JOAQUIN LOCAL ;1:ALTH DTS iZICx <br /> a OR OFFICE USE: 1601�,,w Hazelton Ave. , Stockton, Caliiv--," <br /> Telephone: (209) 466-6781 <br /> ' APPLICATION FOR WELL CONSTRUCTION OR PUMP PERiMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued "7j/ <br /> (Complete In Triplicate) <br /> plication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> —3/or install the work herein described. This application is made in compliance with San Joaquin <br /> ounty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> —3 ADDRESS/LOCATION S_ / 6 � CENSUS TRACT f l <br /> aner's Name Phone <br /> .r, <br /> wdress ,A S �� �/ � c,�, / / City,& .,. . _. <br /> itractor's Name � �, L License # Phone <br /> "'E OF WORK (Check) : NEW WELL / / DEEPEN %/ RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other* <br /> 'TANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> lij <br /> INTENDED USE TYPE OF WELL <br /> CONSTP.UCTION SPECIFICATIONS <br /> _ Industrial Cable Tool Dia. of Well Excavation 2 O <br /> Domestic/private _�( Drilled Dia, of Well Casing g- <br /> Domestic/public Driven Gauge of Casing <br /> g 11. <br /> — Irrigation Gravel Pack Depth of Grout Seal �- <br /> Other Rotary Type of Grout � <br /> Other Other Information <br /> MP INSTALLATION: Contractor <br /> Type of Pump <br /> H P <br /> MP REPLACEMENT: /)e/ State Work Done <br /> P REPAIR: / / State Work Done <br /> STRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> 2r completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> M DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> formation "s true to the pest of my knowledge and belief. <br /> .4ED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> -.3E I FOR DEPARTMENT USE ONLY <br /> PLICATION ACCEPTED BY <br /> Jdn <br /> -ZTIONAL COMMENTS: DATE? I-,- <br /> _ - -- P-HASE II-GROUT INSPECTION PHASE II/FINAL INSPECTION <br /> SPECTION BY DATE INSPECTION BY /,,0-/ DATE/a 5�77 <br /> :ALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> f: H 1426 4/72 1M <br />