Laserfiche WebLink
Iv/ SAN JOAQUIN LOCAL HEALTM DISTRICT <br /> F R OFFICE USE: 1601 E. Hazelton.Ave.;­-Stockton, Calif. <br /> Telephone. ` (209) 466_6781 <br /> PLICATION FOR WELL -CON'STRUCTION-�OR PU1T PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1.•YEAR!FRO i DATE' ISSUED Date Issued / <br /> r' (Complete In-Triplicate) <br /> Application:.is .hereby^made,to the,,San;,Joaquin`Local Health District fora permit to construct t <br /> and/or install the work herein described. This application is"made in compliance rai,th San Joaquin <br /> County Ordinance No-. 1861 andi�the. Rules..and Regulations .of the San Joaquin Local Health ,District: <br /> r '•fie j. __, .�L .... .,.r;-- J d.. � �9', :A- �,.. �5_ - <br /> JOB ADDRESS/LOCATION CENSUS TRACT ' . <br /> r <br /> Owner's'Name-,, Phone <br /> Address _ �• City-, <br /> Contractor's Name C__ License `/j`*PhoneG4 04+t.(r <br /> TYPE OF WORK (Ch(ick) : NEW WELL / DEEPEN /_7 RECONDITION /_/ DESTRUCTION 1-7 <br /> PUMP INSTALLATION% / PUMP REPAIR/ / PUMP REPLACEMENT /_7 <br /> 0 r e t/ �� a .l f <br /> t <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL, FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFIC TIONS <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 -NNWGravel Pack Depth o€ Grout Seal <br /> -- - at <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> s , <br /> PUMP INSTALLATION: Contractor _ L*_r_ k� <br /> Type of Pump -- H.P. <br /> PUMP REPLACEMENT: / / State Work Done i <br /> PUMP REPAIR: f / State Work Done <br /> -DESTRUCTION OF WELL: Well Diameter ? Approximate Depth <br /> Describe Material and Procedure <br /> N <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—work on a new well, I will furnish the_San Joaquin Local'Health District a <br /> WELL DRILLERS REPORT o well and notify them before putting the well in use. The above <br /> information is t u o t my - ledge and belief. , <br /> SIGNED _ �-g� �[” TITL C- <br /> ' - (DRAW PLOT PLAN ON REVERSE SIDE) i <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> - - <br /> APPLICATION ACCEPTED BY DATE r <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE S -d •4r�3 INSPECTION BY DATE to- <br /> .CALL FORA OU.T INSPECTION PRIOR.TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 _. 4/72 1M <br />