Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FT--0F.­OFrICE USE: 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> oil APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 44-Ir-7-5-- <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to constl.,uct <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 r -Pp La-j Phone <br /> Address <br /> S dati"LG�-tea fa�. City <br /> .j ej3_r _a <br /> Contractor's Name r'z!�, ttom' License PhonqJ� L <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN RECONDITION DESTRUCTION 1-T <br /> PUMP INSTALLATION /—/ —PUMP REPAIR /—/—PUMP REPLACEMENT -7 <br /> - <br /> Other /-7 <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 I <br /> ,VDomestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other VRotary 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 UPAIR: State Work Done <br /> .DFqTRUCTION 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 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 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 /> SIGNED (f4f 04'�.-ZMA-, 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 Ijj/FINAL INSPECTION <br /> INSPECTION BY DATE -67-:5 INSPECTION BY DATE <br /> CALL FOR A G& 'FNSPECTION PRIOR TO GROUTING AND FINAL INSPE691 <br /> E H 1426 5/731X <br />