Laserfiche WebLink
k <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> �FOF. 'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 '73_LtS7 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ���-,(a <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ' c(- <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> a and/or install the work herein described. ' This application is made in compliance with Sant Joaquin <br /> 4 County•'Ordinance No. 1862 and the Rules and Regulations of t San Joaquin Local Health District. <br /> Fro,,- l o r 51-vo/J = (6.3_'x20 - t(, <br /> JOB ADDRESS/LOCATION fite / Orz l=S-�o��• S' D J NSUS TRACT <br /> Owner's Name Phone '46 4 Ove!3 <br /> Address 3 Ss 5 ?�l 5� - --- - - - - --- Cityi� ' <br /> Contractor's Name License # z Z 2 1,6 Phoneq:Z 7,f S�f1 <br /> 1 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/ / RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /-7 <br /> Other ,/—/ (j <br /> DISTANCE TO NEAREST: SEPTIC TANK PO! SEWER LINES PIT PRIVY o <br /> SEWAGE DISPOSAL .FIELD CESSPOOL/SEEPAGE PIT OTHER' <br /> INTENDED USE T'A'PE 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 I L <br /> Irrigation Gravel Pack Depth of Grout Seal ,r'a ' <br /> Other _ Rotary Type of Grout <br /> Other Other Information l!y Z .a <br /> PUMP INSTALLATION: Contractor i7.� .� � -�•-c <br /> Type of Pump H.P. .2- <br /> PUMP <br /> -PUMP REPLACEMENT: f I State -Work Done <br /> PUMP 'tEPAIR: / / State Work Done <br /> ,DFgTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> F 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 <br /> } <br /> (DRAW PLOT PLAN(-tN REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: -- - - -- - — <br /> PT I GROUT INSPECTION PHAS III/FI AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE / 73 <br /> CALL FOR A GR INSPECTION PRIOR TO GROUTING AND FINAL INSPECT N. � <br /> E H 1426 5/731M <br />