Laserfiche WebLink
�' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELZ CONSTRUCTION OR PUMP PERMIT Permit No:7.3- /,2 rAl <br /> iV3 io <br /> THIS PERMIT EXPIRES 1- YEAR FROM DATE ISSUED Date Issued _Z,� <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 workrherein described. This application is made in compliance with San Joaquin <br /> County-Ordinance No. 14 2 .and the Rules and Regulations'of the San Joaquin Local Health District. <br /> I� , _ <br /> Y CENSUS .TRACT <br /> JOB ADDRESS <br /> Owner's Name _/_ Y rll� Phone . 79�.- <br /> Address 42 p <br /> City <br /> Contractor's Name iY �� i License -Pho e7d-Z271 <br /> TYPE OF WORK (Check) : :NEW WELL I- DEEP - _.//�ECONDITION�/�,..DESTRUGTION /�— <br /> x�� <br /> PUMP INSTALLATION / PUMP REPAIR / / � PUMP REP LACEMENT , /7 <br /> '.Other / / , _ Y ,. ., �. _ — <br /> DISTANCE TO NEAREST: SEPTIC TANKS SEWER LINES �j'"_c� PIT PRIVY <br /> SEWAGE DISPOSAL FIELD- . @E&SPOOWSEEPAGE-.PIT_p � OTHER � <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial X Cable Tool •- Dia:of--Well--Excavation <br /> Domestic/private —, "Drilled`;- i Dia. of Well Casing <br /> Domestic/public , � Driven r - y Gaugeof Casing • <br /> - <br /> Irrigation :GravelPack ,f iDe' th-of Grout ' al � �e -Z-.__ <br /> g P � <br /> Other Rotary LType of Grout <br /> Q Other a Other Information <br /> PUMP INSTALLATION: Contractor ?°fit d Al S _zr <br /> Type of Pump H.P. -:3 <br /> Y <br /> PUMP REPLACEMENT: j / State Work Done <br /> PUMP REPAIR: �/ IN''State Work Done - * _--_-- <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,ljwork 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 /> SIGNED aE i TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I !� <br /> APPLICATION ACCEPTED B DATE <br /> t ADDITIONAL COMMENTS: y <br /> PHAS INSPECTION P AL INSPECTION <br /> INSPECTION BY DATE '; -2 INSPECTION BY DATE <br /> CALL FOR N EC ON PRIOR TO GROUTING AND FINAL. IN <br /> E H 1426 �� _r _ 7/72 1M <br />