Laserfiche WebLink
SAN JOAQUIN LOCAL° HEALTH DISTRICT <br /> FOR OFFIC2 USE: 1601 'E. Hazelton-Ave:', Stockton, Calif. <br /> Telephone: (209) -,466'-6781 <br /> PLICATION FOR WELL CONSTRUCTION -OR PUMP: PERMIT Permit No. 702-81J5_ <br /> THIS PERMIT MIRES.I' YEAR.FROM DATE ISSUED Date Issued a �' <br /> . . ",-(Complete Iri Triplicate) <br /> Application is -hereb made .to °the-.-San , oaquiri 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.'ltules,. and- Regulations of the: San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION _ D. . M�.6 CENSUS TRACT ' <br /> Owner:s riga P Name �- ! , ,,;:.,. - - hone. <br /> - Y'►� w_ ► <br /> Address �D. C�4 dif�tF :e9� .---- - - City <br /> Contractor's Name License # tf q_7lfPhone (� <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/ / RECONDITION DESTRUCTION <br /> AL <br /> PUMP INSTLATION / / PUMP REPAIR - _PUMP REPLACEMENT /_7 <br /> Other <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 /> Industrial Cable Tool Dia. of Well Excavation <br /> K Domestic/private Drilled . .Dia. of Well Casing <br /> Domestic/public Driven Gauge- of Casing <br /> c Irrigation Gravel Pack Depth of Grout Seal <br /> h Other Rotary Type of Grout <br /> Other Other Information ' <br /> b <br /> _PUMP INSTALLATION: Contractor , <br /> Type of Pump H.P. <br /> 5 <br /> PUMP REPLACEMENT: / / State Work Done t� <br /> f <br /> I e <br /> PUMP REPAIR: 4/ State Work Done R <br /> ,DESTRUCTION 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 neer 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 /> SIGNEDG , +� T LE s t,.P <br /> RA PLO PLAN ON REV SE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ] <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE ITT/FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E HL <br /> 1426 FOR_A QROJUT IN$PE��C I3 DRi©R T91GROUTING AND�FINAL INSPCTIeon � G 4/72 1M <br /> Ci - <br /> Yn- -L- �/l r J f - <br />