Laserfiche WebLink
UIN LOCAL HEALTH DISTRICT <br /> SAN JOAQ Stockton, Calif. <br /> 1601 E. Hazelton Ave C�66-6181 sS7� <br /> fOF.'OFFICE USE. Telephone: ,,.g (` PERMIT Permit No. — <br /> i�-_-. --Y--- APPLICATION .FOR.,L EL <br /> 'CONSTRUCTION OR PUMP Date Issued <br /> 'ten` <br /> TS=pT EXPIRES 1. YEAR FROM DATE 'ISSUED <br /> (Complete In Triplicate) for a permit to construct <br /> fiance with San: Joaquin <br /> rict <br /> Applica <br /> tion is hereby :jade to the San Joaquin LocalH <br /> ealth�tion is t made in Cin Local Realth District- <br /> and/o install the wank herein described. ' This app <br /> Hance-No. 1862 axed the Rules and Regulations of the San Jc�aquir� S TRACT <br /> Coun� Ordi �. CENSUS <br /> � <br /> JOB �DRE SS f LOCA`TIt3I3 Phone <br /> Owner's Name City" PP�� <br /> Address <br /> License # Phone <br /> Contractor's Name - <br /> ( RECONDITION_/ O DESTRUCTION /� <br /> _ DEEPEN 'I� <br /> . TYPE OF <br /> WORK (Check) : NEW WELL '/I / PUNK' REPAIR �/ PUMP REPLACEMENT /?� <br /> PUMP INSTALLATION E/ �,. <br /> Other S <br /> f SEWER LINES PIT PRIVY OTHER <br /> t DISTANCE TO NEAREST: SEPTIC TASK _ CES PS OOL/SEEPAGE- PIT <br /> SEWAGE DISPOSAL FIELD ____ <br /> III UP <br /> CONSTRUCTION SPECIFICATI IS. <br /> TYPE OF WELL .�IVf' � <br /> INTENDED USE Cable Tool Dia. of Well Excavation <br /> Industrial <br /> Drilled Dia. of Well Casing <br /> Domestic/private Driven Gauge of Casing <br /> Domestic/Public Depth of Grout Seal <br /> Gravel <br /> Pack P <br /> Irrigation "�""" Rotary - <br /> Type of Grout <br /> E - Other - 'e„ =_ - Other Other Information i <br /> Contractor H.P. <br /> pu:rP INSTALLATION: Type of Pump = "� <br /> r _ <br /> State Work,Done ` <br /> PUMP REPLACEMENT: / D: <br /> State Work Done <br /> PUMP. 'tEPAIR: Pim- 3. <br /> _ �- � � Approximate Depth ___�_� <br /> -FC R-UCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> cal <br /> lth <br /> hereby agree to comPly with all laws and r�gu1ulatin ations ewellIC! rict <br /> econstruction.San Joaqu'rj LQWithinaFIFTEENtDAY`. <br /> I Y g <br /> and the State of California Pertaining to or w g <br /> � work on a new well, I will furnish the San Joaquin Local He��ha�aver c <br /> after completion of my <br /> r <br /> WELL DRILLERS ORT of .the well and notify them before putting the well in use. <br /> information to t est f my knowledge and belief. <br /> s <br /> SIGNED DRAW PLOT PLAN dN REVERSE SIDE) <br /> . FOR DEPARTMENT USE ONLY <br /> w PdASE I <br /> DATE f� <br /> APPLICATION ACCEPTED BY PHASE I�/ �I. LNSPECTION <br /> ADDITIONAL COMMENTS- ATE '��'�` <br /> r PHASE II GROUT INSPECTION INSPECTION BY <br /> INSPECTION BY DATE <br /> 3 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. �� . 5/731M <br />