Laserfiche WebLink
SAN JOAQUiN .LOCAL HEALTH DISTRICT <br /> TOr.�OF ICE USE: 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) 466-67$1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> t <br /> THIS PERMIT EXPIRES 1 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 Joaqui <br /> County Ordinance No. 1$6 and the Rules nd Regulations of the San Joaquin Local Iieal.th District. <br /> JOB ADDRESS/LOCAT ON �"'� CENSUS TRACT <br /> Owner's Name Al. P Phone� �J �� <br /> Address fz/c?z A::;�t - City . <br /> eg�� <br /> / f�6�ba-tom <br /> Contractor',s Name R License <br /> TYPE OF WORK Y(Check): �NEV Wa / / " DEEPEN':_ =-RECONDITION'7-/`- DkStkOCTION__�T_ <br /> MP . <br /> PUMP INSTALLATION / / PUREPAIR. PUMP REPLACEMENT 17 <br /> Other f f <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY � <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well. Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> ,g PUMP INSTALLATION: <br /> Contractor <br /> Type of Pump H.P. <br /> j PUMP REPLACEMENT: / / State Work Done <br /> �f <br /> `i PUMP 'tEPAlk: State Work Don <br /> } <br /> DFRTRUCTION OF WELL: Well Diameter y Approximate Depth <br /> Describe Material and Procedure <br /> 3 <br /> 'S <br /> I hereby agree to comply-.with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well "construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District l <br /> SMELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. <br /> SIGNED pTITLE <br /> _ -- --- _ &--IA4-) <br /> - (DRAW PLOT PLAN ON REVERSE SIDE) <br /> :E FOR DEPARTMENT USE ONLY <br /> ' PHASE I <br /> VAPPLICATION ACCEPTED BY ! DATE /Z 7j <br /> ADDITIONAL COMMENTS: 4 <br /> PHASE II GROUT INSPECTION P4A$V(/jII/FINAD INSPECTION f- <br /> INSPECTION BY DATE INSPECTION BY DATE - <br /> i 7CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECT N. <br /> q/.73im <br />