Laserfiche WebLink
r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOI.OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> r Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 4e !u <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date, lssued i <br /> (Complete In Triplicate) <br /> Application is hereby made to the Sari 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 Joaquii <br /> County Ordinance No. 1862 and the Rules. and Regulions of the San Joaquin Local. Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name -- - _Al ( n / Phone <br /> Address �Q � e� r .. �T City - - <br /> Contractor's Name ak414 [� License # 4.619Z Phone <br /> ' TYPE OF WORK (Check) : NEW WELL DEEPEN '/_! RECONDITION / // DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR--/—/ PUMP REPLACEMENT /_ <br /> Other L/ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVYr - . <br /> SE1AGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT �- = dnmk , <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 /> Damestic/public' Driven , 'fr Gauge of Casing 12, <br /> A_Y .Irr gation �"'"" gavel Pack Depth -of Grout Seal <br /> Other � ;:. Rota y Type of Grout - 4�Y <br /> Other Other Information - <br /> vGIM <br /> PUMP INSTALLATION: ContrJctor / <br /> Type of Pump ! \ H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'ZEPAIR: / J_ ..State -.Work.:Done •, � � <br /> DI? TRUCTION OF WELL: Well Diameter . Approximate Depth <br /> Describe Material and Procedure " `— - <br /> AI hereby agree to"c.omply. w,ith all laws and regulations of the San Joaquin Loda2 _Health District <br /> and the State of California pertaining to or regulating well "construction.` Within FIFTEEN DAYS <br /> j, 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 best of my knowledge and belief. ; <br /> ;i SIGNED TITLE s <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL CO_ MMENTS: <br /> PHASE II GROUT INSPECTION PHASE IIi F INSPECTIO <br /> INSPECTION BY DATE .- /r 7 INSPECTION BY -DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GR UTING AND FINAL INSPECTION. <br /> 4 E H 1426 .5/731M <br />