Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT , <br /> FOR OFFIG''Z USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) ' 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No: - S <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 2-1612_ <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 Joaquin, <br /> County Ordinance No. 1862 and the Ru es and Regulations of the San Joaquin Local Health District. <br /> �. ,. <br /> JOB ADDRESS/LOCATION D''L- 8 A � ���L lV � D F 7"����/ � 1�' 5 t�7� __ _ CENSUS TRACT <br /> Phone !/61> 4E/ Sd <br /> Owner s Name --- <br /> Address 6cc- City �� <br /> s-z� <br /> Contractor's Name License # a Phone 7'c{5lp S` <br /> f <br /> TYPE OF WORK (Check) : NEW WELL /� DEEPEN:; /. / RECONDITION /� DESTRUCTION /� <br /> /-7 <br /> PUMP INSTLATION Jam/ PUMP REPAIR/ / PUMP REPLACEMENT <br /> AL1 <br /> Other <br /> DISTANCE TO NEAREST: . SEPTIC TANK SEWER LINES PIT PRIVY <br /> ' SEWAGE DISPOSAL FIELD `CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS .F <br /> Industrial �(-- Cable Tool 'Dia, of Well Excavation t <br /> Domestic/private Drilled Dia. of Well Casing _iEF` . <br /> �- Domestic/public Driven Gauge of Casing /'� <br /> Irrigation Gravel Pack Depth of Grout Seal s O <br /> Other Rotary Type of Grout G911--e4-y- <br /> Other- Other Information <br /> PUMP INSTALLATION: Contractor `'; � L S-7 f <br /> Type of Pump e, H.P. f <br /> PUMP REPLACEMENT: / / State Work Done y <br /> PUMP REPAIR: 4 / / 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, I will furnish the San Joaquin Local Health Distritt a.� <br /> III 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 /> f SIGNED TITLE <br /> (DRAW-PiEOT PLAN ON REVERSE SIDE <br /> FOR DEP TMENT USE ONLY - <br /> PHASE I <br /> APPLICATION ACCEPTEDBY, DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE .J�'r'�3+' INSPECTION BY DATE p <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION.3 <br /> E H 1426 7/72 1M <br />