Laserfiche WebLink
SAN JOAQUIN -LOCAL-HEALTH DISTRICT <br /> FO£__OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: _ (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No Z7 -333 <br /> THIS PERMIT EXPIRES 1 YEAR .FROM DATE ISSUED Date Issued _S- 7 <br /> F E (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/LOCATIONI l3�•i /]�/� CENSUS TRACT - <br /> -� <br /> Owner's Name rf�F�=l� - - Phone <br /> Address ZZL <br /> x _ _ City ' ' <br /> Contractor's Name License Phan <br /> TYPE OF WORK (Check) : -NEW WELL DEEPEN '/ / RECONDITION DESTRUCTION /`77 <br /> PUMP INSTALLATION / / PUMP REPAIR / / `PUMP REPLACEMENT <br /> Other�/ -/, <br /> DISTANCE TO NEAREST: SEPTIC TANK' SEWER LINES PIT PRIVY, Q <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> V1 " <br /> INTENDED USE TYPE. OF WELL .CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool _ Dia:. ^of-Well Excavation <br /> Domestic/private Drilled Dia. of Well CasingZR <br /> _ Domestic/public Driven Gauge of Casing <br /> Irri: anon 4pzh ofw_G owt-Seal._. Cl <br /> t <br /> Other Rotary.., C436 4 <br /> Other Other Information <br /> I <br /> PUMP INSTALLATION: Contractor p <br /> Type of Pump U H.P. ' P57 , <br /> PUMP REPLACEMENT: / / State Work Tone �44 <br /> PUMP `tEPAIR:, / -/ State Work Done <br /> f <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 /> J and the State of California. pertaining to or regulating well. 'construction. Within FIFTEEN DAYS 1 <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 /> E i <br /> SIGNED TITLE VVV <br /> (DRAW PLOT PLAN ON REVERSE SIDE — � <br />�. FOR DEP MENT -USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY._ DATE <br /> ADDITIONAL CO�MNTS: 7-77-7 <br /> PHA E II OUT INSPECTIO PHAS I/ NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE. <br /> CALL FOR GROUT JUSl'ECTI4N�.PRZ RTTO•GROUTING AND FINAL IN ECTION. <br /> E H 1426 14/71im <br />