Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OMCE SE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �5 3 <br /> 9Hs -7z- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date issued �-13 "7Z <br /> (Complete In Triplicate) <br /> Application is hereby ma- e 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 /> X LOCATIONy '� ,4 T CENSUS TRACT S <br /> JOE ADDRESS/ ,,) t <br /> Xowner's Name l- <br />-*74 Address L / a City <br /> ,1 �1 <br /> Contractor's Name I�RV -SI/o License # I Phone <br /> TYPE OF WORK (Check): NEW WELLDEEPEN '/ / RECONDITION /-T DESTRUCTION /r7 <br /> PUMP INSTALLATION <br /> / I PUMP REPAIR/ I PUMP REPLACEMENT /� <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK g. SEWER LINES IT PRIVY <br /> %- SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing 9P <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other other information <br /> PUMP INSTALLATION: ContractorI!F <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> .RESTRUCTION 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 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 TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PRASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASFL II GROUT INSPECTION PHASE III/FINAL INSPECTIW74Z <br /> INSPECTION BY r DATE INSPECTION BY DATE <br /> CALL FOR A GROUT. INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E 4/72 1M <br /> H 1426 <br /> 1 <br />