Laserfiche WebLink
r ` SAN JOAQUIN LOCAL HEALTH DISTRICTIr <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUTIP PERMIT �� Pp_rmit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 an the Rules at U1 LL s of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION y 1y►�,Q.� Lc1 CENSUS TRACT <br /> Owner's Name /Ld p Phone / / �Z_ :)_t_17 <br /> AddressP k_ �f �; �L Citr/Ls.�' <br /> -- y <br /> Contractor's Name �C�c�r� License I� Phone <br /> TYPE-OF WORK (Check) : NEW WELL /� -DEEPEN / / RECONDIT ON_/ F DESTRUCTION /- <br /> PUMP INSTALLATION / / PUMP REPAIRPUMP REPLACEMENT /_7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK a SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS N <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing y O <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION:, Contractor kO <br /> Type of Pump H.P. i <br /> PUMP REPLACEMENT: J / State Work Done <br /> PUMP REPAIR: State Work Done <br />,�}ESTRUCTION 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 /> G' <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA III FINAL INSPECTION <br /> INSPECTION BY I DATE INSPECTION BY DATE .r I • <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M ., <br />