Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 75-J/3�w <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /o-7-75`— <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 Rules and Regulations o the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> Owner's Name Phone <br /> Address a� City <br /> Contractor's Name .tC/ License #_9X6,1YZ Phone <br /> TYPE OF WORK (Check) : NEW WELL /? DEEPEN RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION /+-f _PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other / / T <br /> DISTANCE TO NEAREST: SEPTIC TANK 31SEWER LINES PIT 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 �A <br /> Domestic/public Driven Gauge of Casing V) <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor ; <br /> Type of Pump H.P. 1 <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR- - --..—. / J State Work Done <br /> Af <br /> ,DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> _ - Describeeri 1 and Procedure <br /> I hereby agree to comply wTth all laws and \r latio s of the S oaquinLocal 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 /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE /FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT NSPECTION PRIOR TO GROUTING AND FINAL INSPIZION. <br /> E H 1426 7/72 1M <br />