Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> r' .,O1FICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> E Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP-PERMIT" Permit No. ,_9 710 <br /> E Y _ <br /> i THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued .z__ � e <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 Joaquin <br /> County Ordinance .No. .1862 an the Rules a d Regulations of the San Joaquin Local fleal.th District, <br /> 23 9V ,5� ON CON , <br /> JOB ADDRESS/LOCATION— ,*.., 4 GV, C-( 1 Pd A,- 0 CENSUS TRACT <br /> Owner's Nance ,1/ jL/ Ya A/ Phone <br /> I Address ��f� 1/ /4// O City <br /> Contractor's Name License # Phone <br /> " TYPE�OF WORK (Check). -NEW�-WELL:7AATION <br /> DEEP �T�/_ <br /> EJ RECONDITION- /_-/—DESTRUCTION <br /> PUMPaINST PUMP REPAIR / / PUMP REPLACEMENT /_ <br /> -- ,. Other / / C��.T7-vf�G= Pi -/�..�.� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> { <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 /> f <br /> PUMP INSTALLATION: rctactor ,�, <br /> Type of Pump H.P. yid-- . ^ <br /> PUMP REPLACEMENT: { / State Work Done <br /> PUMP REPAIR: <br />� / J State Work Done <br />_ .pF�TRUCTTON"_0_F WELL: e 1 �ameter :' _ f '�►PProx �ate I3egth`-�""�' �'�""�` <br /> Describe Material and Procedure <br /> F <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> 4 <br /> and the State of C'alifornia,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 />'i WELL DRILLERS REPORT of. the well and notify them before putting the well in use. The above <br /> information is true tot best of my knowledge and belief. <br />,Y SIGNED TITLE <br /> y (DRAW PLOT PLAN ON REVERSE SIDE) <br /> ! <br /> ORAETMENT USE ONLY <br /> 4 PHASE I <br /> APPLICATION ACCEPM BY DATE - <br /> ADDITIONAL COMMENTS: t' lig—s g1 R <br /> PHASE I GROUT INSPECTION PHXW FINAL INSPECTION <br /> INSPECTION BY ;� - DATE INSPECT" <br /> N BY DATE <br /> CALL ICOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 5/731M <br />