Laserfiche WebLink
r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Zl=?_447� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date lssued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San 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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION _23 CENSUS TRACT Sq <br /> Owner's Name _r / ( = �'/y p 1t�CcJ --- -- Phone <br /> Address ->_ UcU /.l �� City <br /> Contractor's Name IAILicense Phone <br /> !�% /1 <br /> �- !� 7�'E,� <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_7 RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> r / SEWAGE,DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> �ld-4U r c-r'Gi_ _. /r fj4 , t. ^�v �. .•N i, I b <br /> INTENDED USE TYPE OF WELX . CONSTRUCTION SPECIFICATJON <br /> Industrial Cable Tool Dia, of Well Excavation ` <br /> Domestic/private Drilled Dia. of Well Casing _IV Nr <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 AV <br /> NIF <br /> l� <br /> PUMP INSTALLATION: Contractor / <br /> Type of Pump �,cc .� %✓/" H.P. <br /> PUMP REPLACEMENT: / State Work Done- <br /> h <br /> PUMP REPAIR: / / State Work Done <br /> -pESTRUCTION 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 is7true to the best of my knowledge and belief. <br /> SIGNED <br /> TITLE <br /> C:PRAW 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 III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ,, DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />