Laserfiche WebLink
No <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF.:OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> r AVE EFS Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,&_ z! <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3-_Z5 -74 <br /> (Complete In Triplicate) <br /> I 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 SaA Joaquin Local Health District. <br /> 2-07---oev--cl Y <br /> JOB ADDRESS/LOCATION �--,� a, eASUS TRACT <br /> Owner's Name — � III-' rig rt_M's Phone .:ZQ�� _ <br /> - .._ <br /> AddressC <br /> k City . zS SJ��� . <br /> ` Contractor's Name License Phone &Z <br /> TYPE OF WORK (Check) : NEW WELL '/ / DEEPEN -/—/ RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / J PUMP REPLACEMENT <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 /> Industrials Cable Tool Dia. of Well Excavation <br /> ( Domestic/private,. Drilled Dia. of Well Casing � <br /> { Domestic./public _Driven Gauge of Casing <br /> Irrigation ' ..--�--�_ <br /> j g Gravel rack - Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. " <br /> PUMP REPLACEMENT: State Work Done �F ,2 f, p - n•S�.QLG .L/ -'��v <br /> PUMP `REPAIR: f / State Work Done <br /> ,DFfiTRUCTION OF WELL: Well Diameter : <br /> i Describe Material an :d Procedure' Approximate Depth <br /> I hereby agree to comply-with all laws and regulations.of the San Joaquin Local Health District <br /> I <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 /> i SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> i <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE - <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROIN INSPECTION PHASE I/FIN INSPECTIO <br /> INSPECTION BY DATE INSPECTION BYDATE <br /> CALL FORA GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTI <br /> E .H 1426 <br />