Laserfiche WebLink
SAN JOAQUIN LOCAL -HEAiTH DISTRICT <br /> 4 �'�'- 1601 E. Hazelton Ave. , Stockton, Calif. <br /> riot :DFIICI: USE: �j <br /> Telephone:, (.209) 466=6781 r"L � d <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No./7f-- <br /> APPLICATION <br /> o. 1 <br /> Z1�5 <br /> THIS: PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> .I� . (Complete In Triplicate) permit to construct3 a <br /> Application is hereby made to the San Joaquin Local Health District for a p <br /> and/or install the work herein described. - This application is made in compliance-with San Jaaquint <br /> s land Re�ulat no of the San Joaquin Local Heath Disri�ct. <br /> County Ordinance No. 1,862 ar►d the Rule <br /> :Z 50(* CENSUS TRACT <br /> JOB ADDRESS/LOCATION 17 8Bea <br /> w <br /> ill V A1>01Z UAC.t" a LL-A Phone <br /> Owner`s Name '+41- <br /> 2—SMS �. L 0x 6. city , <br /> Address alc�S�2 `�' 17):7s <br /> d (L Gt ca.1.k NG Licensed Phone' <br /> Contractor's Name <br />' Chacic�'� ' NEW ;iWELL / / DEE / RECONDITION / / DESTRUCTION /`7 <br /> TYPE OF WORK ( } .. <br /> PUMP INSTALLATION f PUMP REPAIR /—PUMP REPLACEMENT /� � <br /> k Other <br /> 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK SE%LINES PIT PRIVY Ct <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER O(� <br /> R . <br /> p . CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE 1 ,� TYPE OF WELL C� <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Drilled Dia. of Well ,Ca•sing.' ' c. <br /> Domestic/private Gauge o Casing <br /> Domestic/pub lac ~--"" Driven-- �•-� E <br /> Irrigation._ Gravel Pack- Depth of Grout Seal 6,5 <br /> Other Rotary Type of Grout <br /> Otheir Other Information <br /> PUMP -INSTALLATION: - Contractor <br /> ' Type of Pump H.P. <br /> ...n , 1a. r..; <br /> PUMREPLACEMENT: / / State Work Done <br /> ,E <br /> PUMP •tEPAIR: # / / State Work hone <br /> Approximate Depth,._�,� <br /> DFgTRUCTION OF WELL: Well Diameter f - <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 woik 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 /> informat n is tiue to t e best of my !k}nowledge and belief. <br /> ! UU oma. 416zv � . TITLE <br /> SIGNED <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PIJASE I I DATE <br /> APPLICATION ACCEPTgD BY <br /> F ADDITIONAL COiZMNZS: PHASE FIN INSPECTI N <br /> PHAS9' II GROUT INSPECTION DATE <br /> INSPECTION BY 1 DATE INSPECTION BY <br /> 07 <br /> CALL FOR A GROUT INSPIaCTION PRIOR TO -GROUTING AND FINAL INSPECTION. �/� /PX a <br /> i4 5/731M <br /> U 7AIA - - <br />