Laserfiche WebLink
I <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> i�OF:OFI�ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � cJ <br /> THIS PERMIT EXPIRES 1. YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby `ade to the San Joaquin Local Health District for a permit to construct <br /> and/or install the world herein described. ' This application is made in compliance with San Jpaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIONI.� CENSUS TRACT <br />{ Owner's Name Il�r� i�/ � ,a��_ Phone -� <br /> t <br /> Address i/r City zreklv�e_e7_;04 <br /> II <br /> .Contractor's Name - �� �� License #ijaiA2Z2, Phone <br /> a <br /> TYPE OF WORK (Check) : INEW WELL. DEEPEN /—/ RECONDITION / / DESTRUCTION /_ <br /> PUNT' INSTALLATION &V PUMP REPAIR / I PUMP,,REPLACEMENT /� <br /> Other I I — — <br /> SF <br /> i <br /> i, DISTANCE TO NEAREST: SEPTIC TANKZ. SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD id ,, CESSPOOL/.SEEPAGE PIT,/dll OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation v <br />" k—' Domestic/private. Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge-of Casing <br /> Irrigation Gravel Pack De'�th of- Gr6xit-Seal <br />' Other Rotary Type_of Grout <br /> -- �� Other Other Information ' <br /> PUMP INSTALLATION: Contractor P-21--k <br /> ! Type of Pump .r �Clr'Y, ��1: P• . <br /> i <br /> k PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> PFIRTRUCTION OF WELL: Well Diameter Approximate Depth <br /> f ; Describe Material and Procedure <br /> 1 I hereby agree to comply with all laws and regulations ofithe San Joaquin Local Health District <br /> I 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 /> 14ELL DRILLERS REPORT Of theweil-and notify `them �efore putting the well in use. The above <br /> information is true ta� the best of my knowledge and belief. <br /> I <br />` SIGNED !h TITLE <br /> 8 (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I i� <br /> APPLICATION ACCEPTED .BY DATE -ZI717 <br /> ADDITIONAL COMrFENTS: 11 . <br /> k <br /> PHASE4U :'GROUINSPECTION PHASE IIIINSPECTION <br /> INSPECTION BY DATE 3 - INSPECTION BY DATE <br /> il <br /> k CALL FOR A GROUT IN6EC ION PRIOR TO GROUTING.AND FINAL INSPECTION. <br /> E H 1426 IN 5/731M <br />