Laserfiche WebLink
- SAN JOAQUIN LOCAL HEALTH DISTRICT _ <br /> VFICE 0SES 1601 E. Hazelton-Ave.', Stockton, Calif. <br /> Telephone: (209),;466-' 6781 <br /> APPLICATION FOR WELL CONSTRUCTION .OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES. 1 YEAR FROM:DATE `ISSUED` • ,Date Issued " <br /> <Complel a In Tr=ipiicate) <br /> Applicatiori; is hereby made: to the= San, Joaquin Loeal 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,prdi.nance No: 1862 an&�the Ru]lesi:and: Regulations: of ;the San in <br /> Local °Health District. <br /> JOB ADDRESS/LOCATION 3820E. lm _r+d_Dri,yea1��dj� Ce11 floe Q -CENSUS TRACT, <br /> Owner's,,Name- h <br /> a3Tiri,: Pone. <br /> Address 3820 E. tmoncl Drive ..�,;,. -Cit <br /> — - Y <br /> Contractor's Name a1 .Tom in E= C=A=m r License # 271goo Phone g 4� <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN RECONDITION RECONDITION /7 DESTRUCTION /_7 <br /> PUMP INSTALLATION/ / PUMP REPAIR-/—/ PUMP REPLACEMENT /_j <br /> Other L7 Check 7T EP ptmpa <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 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 /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: /7 State Work Done <br /> ,DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health Diatrili <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work on anew 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 t. <br /> information is true tot best of my knowledge d belief. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY � DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE SII FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE ,/6 2-2-71- <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> B. R 1426 4/72 1M <br />