Laserfiche WebLink
s <br /> SAN 30AQUIN LOCAL HEALTH DISTRICT i <br /> FOI,,:-OFFICE USE: ' 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP. PERMIT Permit No. 7 <br /> THIS PERMIT EXPIRES l 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 and the Rules and Regulations of the San Joaquin Local .Health District. <br /> JOB ADDRESS/LOCATION �4mf-�c'pCENSUS TRACT <br /> Owners Name �_ . �f, / m r Phone l?z _7110 <br /> C'9 �. �I / - - - City .4041 <br /> Address _` . .-_----- <br /> ``,. > ----a <br /> Contractor's Name d df,�oo /f�Y �t!/`/�C License ���'y� � Phone��r `J�� <br /> _ - .... �. <br /> TYPE OF WORK (Check): NEW WELLDEEPEN /_/ RECONDITION /_7 DESTRUCTION /_7PUMP INS!e�!LATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANKx� SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> Wt. F <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS E <br /> Industrial Cable Tool Dia. of Well Excavation w <br /> r <br /> 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 _ff <br />` Other Other Information �� f <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUHP REPLACEMENT: / / State Work Done <br /> __ <br /> —S-tate-Work-Done -- -_- - <br />.x.RESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> EDescribe 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 /> inform o is true to the best of my knowledge and belief. <br /> SIGNED 9 Z TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> M FOR DEPARTMENT USE ONLY <br /> 1 PHASE I �/ <br /> APPLICATION ACCEPTED BY DATE f�T—22 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PRASE III/FINAL INSPECTION <br /> INSPECTION BY DATE Loi -7�, INSPECTION BY DATE 6/Z'T.3_ _ <br /> E <br /> CALL FOR A_GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. - <br /> - <br /> E .H 1426 7/72 1M <br />