Laserfiche WebLink
SAN JOAQUIN'LOCAL HEALTH DISTRICT <br /> FOf..OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> TI�HIS PERMIT EXPIRES 1. YEAR FROM DATE 'ISSUED Date Issuedz �7¢. <br /> (Complete In Triplicate) <br /> Application is hereby madeito 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 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION- CENSUS TRACT <br /> Owner's Name C G CSO' � � L� Phone 3_6 g-4S,5' Z <br /> Address . f �Z 'iw N D. F& k A A T city t j C A L/F- <br /> Contractor's Name +.Lc.[. License #f8E4(6�0 Phone <br /> TYPE OF WORK (Check): NEW �WELL / DEEPEN '/ / RECONDITION '/ / DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PL'2rfP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other ./ / — <br /> DISTANCE TO NEAREST: SEPTIC TAINK gyp ' SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> II <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS N ' <br /> Industrial Cable Tool Dia. of Well Excavation 1 <br /> Domestic/private Drilled Dia. of Well Casing 1:2" <br /> Domestic/public r Driven Gauge of Casing 10 r'A6 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> m Other Other Information ' <br /> f <br /> PUMP INSTALLATION.. � Contractor �'S`]6. <br /> ` Type,, of Pump 7 -/ C{.f tc.�P H.P,. ' A, .; <br /> PUMP REPLACEMENT: / / I State Work Done <br />-PUMP--EPAI-R,: x State Work�Done = _ - - <br /> .DFgTRUCTIONOF WELL: Well. Diameter Approximate Depth <br /> T 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 'coxstruction. Within FIFTEEN DAYS <br /> after completion of my work 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'lbest of my knowledge and belief { - -• <br /> ► y . TAa 1 <br /> SIGNED ITLE <br /> F e ii: -' (MM PLD AN ON REVERSE SID <br /> F � <br /> _... . <br /> ' I ... FOR DEPARTMENT USE ONLY: <br /> PHASE I <br /> APPLICATION--ACG]`PTED -BY-.• DATE. <br /> ADDITIONAL COMMENTS: i1i <br /> ..-.., <br /> PHASE ;II .GROUT INSPECTION + _ PHASE:II:I/FINAL 'INSPE'CTION <br /> INSPECTION BX ? DATE. INSPECTION. BY .. DATE . <br /> C�.4Ty x- (3i 1 G t4U fiFSHECsTI©NF PRIOR- -GROUT-ING-AND FINAL-INSPECTION __...A ...,..._�._. ..__ <br /> } -E H 1426- - F 5/731M f <br />