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. 3 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued.` <br /> 13 <br /> (Complete In Triplicate) ��ST 7.p_0to <br /> Application is hereby made to the San Joaquin Local Health District .for a pe�mit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaqui <br /> County Ordinance No. 1852 and the Rules and Regulations of the San Joaquin Local Health District. <br /> _=� <br /> JOB ADDRESS/LOCATION" ✓ ,Zoe q CENSUS TRACT <br /> t <br /> Owner's Name Phone <br /> Address .4 0-0 City � <br /> Contractor's Name .� C License # f.,} Phone 6 <br /> 6) <br /> .--TYPE OF WORK (Check) : NEW WELL /7 DEEPEN /_7 RECONDITION /_7 DESTRUCTION /_7o <br /> PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT /'7 0 <br /> Other /% — +R <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> i. <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> _ cc Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation . .Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> "T Other Other Information <br /> i <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump si <br /> a .. <br /> H.P. <br /> PUMP ` / / State Work Done <br /> p PUMP REPAIR: / / State Work Done <br /> 4i .pESTRUCTION OF WELL: Well Diameter <br /> . .._ 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 knowled a and b.plief. <br /> f <br /> SIGNED00 <br /> (DRAW PL LAN ON REVS SIDE <br /> FO <br /> PHASE I EPARTM :NT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS.- <br /> PHASE <br /> OMMENTS:PHASE II GROUT INSPECTION PHASE II /FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE _l <br /> r <br /> CALL, FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. a Y$,3 y <br /> E H 1426 7/72 1M <br />