Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR WXE USE:. 1601 E. Hazelton Ave. ,-Stockton, Calif. <br /> • Telephone: (209)466-6781 <br /> APPLICATION FOR.WELL' CONSTRUCTION OR PUMP PERMIT Permit No.;3-- 35� <br /> THIS'r.PERMIT EXPIRES 1"'YEAR FROM DATE ISSUED Date Issued <br /> F (Com�lete In Triplicate) 4 <br /> Application lis:;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. 1862- and the`Riiles axid Regulations of the San Joaquin Local Health District. <br /> ,o.. s.. <br /> JOB ADDRESS/LOCATION V tENSUS 'TRACT <br /> Owner's Name--,, , -. > ..,.r Phone'M-.-... <br /> 111,/ <br /> Address Cityl���� � t <br /> Contractor's Name C'1'6 r License # Phone -] <br /> TYPE OF WORK (Check): NEW WELL /r-7r-- DEEPEN / / RECONDITION /_/ DESTRUCTION /-7 <br /> I <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other /-7 <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 <br /> r <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private. Drilled Dia. of Well Casing ' <br /> Domestic/public �L Driven Gauge of Casing <br /> Irrigation ✓ Gravel Pack Depth of Grout Seal _ �f <br /> Other Rotary Type of Grout i <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor K•� �1 � <br /> Type of Pump .. H.P. f� <br /> PUMP REPLACEMENT: / / ' State'Work Done <br /> PUMP REPAIR: / / State Work Done <br /> .pESTRUCTION 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 th@m 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 /> PHASE I j <br /> APPLICATION ACCEPTED BY D <br /> ADDITIONAL COMMENTS: <br /> PRASE II GMOO,"NSPECTION PHASE. / ION <br /> INSPECTION BY / / DATE INSPECTION BY` <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSP7 <br /> E H 1426 1 7/72 IM <br />