Laserfiche WebLink
a <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> lr.j.:OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. j /�� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE -ISSUED, Date Issued 6-3-7.S a <br /> (Complete In Triplicate) ,s <br /> Application is hereby made to the San Joaquiri 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. 1.862 and the Rules and Regulations ,of the San Joaquin Local kteal.th District. <br /> JOB ADDRESS/LOCATIONAI - © CENSUS TRACT ' <br /> t <br /> Owner's Name Phone <br /> Ad�� , 0 � City , d <br /> dress s , <br /> Conz aetar's�Name - .� - w cense1A1v2..:ZC4, /Phone .,.. . i - <br /> TYPE OF WORK (Check): NEW WELL ,s!l DEEPEN /_/ RECONDITION / { DESTRUCTION /? <br /> PUMP iNSTALLATION REPAIR ' / PUMP REPLACEMENT /-7 <br /> Other / <br />' DISTANCE-.TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> f - SEWAGE DISPOS FIELD CESSPOOL/SEEPAGE PIT OTHER - <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ; <br />` I ustrial � able Tool Dia, of Well Excavation �I <br /> Domestic/private Drilled I)ia. of-Well.:..Casing <br /> r Domestic/public Driven Gauge of Casing __,_. 1 ��•�„ <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Ocher Rotary . Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor . . <br /> Type of Pump H.P. <br /> PUNiP REPLACEMENT: / / _State Work Done <br /> PUMP UPAIR: / State Work Done <br /> ,DF-,TRUCTION 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 t ue to the be t f y knowledge and belief. <br /> 11; 4 <br /> ---SIGNED TITLE <br /> rn (DRAW T PLAN ON REVERSE SIDE) <br /> OR DEPARTMENT USE ONLY <br /> PHASE. I r` 02 /3 <br /> APPLICATION ACCEPTED BY C. •� DTE ��. <br /> F' ADDITIONAL, COMMENTS. O!a70 7 <br /> - n <br /> PHASE II GROUT INSPECTI N PHASE I /FINAL INSPECTION <br /> INSPECTION BY DATE o2/ ' INSPECTION BY DATE <br /> CALL FOR A GROUT-INSPECTION -PRIOR TO GROUTING AND FINAL INSPECTION. <br /> 5/73lm <br />