Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. ; Stockton, Calif. <br /> Telephone : (209) 466-6781 ?L-3 <br /> y0 APPLICATION FOR WELL. CONSTRUCTION OR PUMP PERMIT Permit No. <br /> a <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �y <br /> (Complete In Triplicate) r <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 JoaquiYt <br /> County Ordinance No. 1862 and the Rules and Regulations of /the San Joaquin Local Health District. <br /> JOB ADDRESS/b96AT49N o 4 4e CENSUS TRACT <br /> Owner t s Name _ R'A'1 V 4_.- , Y' i '�/1'f Phone <br /> t <br /> Address City. <br /> Contractor's Name Yy"U• t4 S S License &4 _"honezzlz-2 71; <br /> 1 <br /> TYPE OF WORK (Check) : NEW WELL / DEEP /_% RECONDITION /� DESTRUCTION /� <br /> PLTMP'INST�LATIOIV% PUMP REPAIR / / PUMP REPLACEMENT /� <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK ZSEWER LINES PIT PRIVY-•-- i <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USEi TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation /01", <br /> Domestic/private $rDrilled Dia, of Well Casing. <br /> Domestic/public Driven Gauge of Casing � Z_ <br /> Irrigation Gravel Pack 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: /_7 StateWork Done ` J` <br /> PUMP REPAIR: / / State Work Done <br /> ,DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i 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 rfurnish 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 /> SIGNED TITLE .ON� df-u Gr1L, <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE C0-'(&h.2_ <br /> ADDITIONAL COMMENTS: <br /> PHASE II T INSPECTIONPHASE INSPECTION <br /> INSPECTION BY DATE INSPECTION BYLZ�jTE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSP <br /> E H 1426 V 7/72 1M <br />