Laserfiche WebLink
SAN JOAQUIN LOCAL- HEALTH DISTRICT <br /> FOR.0- FICE USE: 1601 -E. Hazelton Ave. , Stockton, Calif. <br /> r Telephone : (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ZJO- 27/3 . <br /> 27( �� <br /> r <br /> � �tTHIS PERMIT EXPIRES 1 YEAR FROM DATE' TSSUED Date Issued_"/7-7.1 <br /> � 2a _��, �4- (Com 1 <br /> ! A p ete In Triplicate) �A Q0'7 _ /00 _eD <br /> pplication 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 San Joaquin <br /> wi <br /> Cgu-nt a� No 1862 ar�d�he Rules and Regulations of the San Joaquin Local Huth District.. <br /> .J� , <br /> AB ADD RS//LOCATION I" CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address <br /> City" <br /> �'_•, ,_ :. <br /> Contracfio 's Name <br /> ZXe-Lii& License # // 1"Fhone <br /> TYPE OF WORK (Check) ,NEW W&L-L -UEp Y" ""�'`""_ W .„ ,,,�„ .,_ <br /> . « tet;• �._. 5 .. _y"` _ RECONDITION I I DESTRU(sTION I? a y� <br /> --�- PUMP INS ,ATM I�I PUMP .-REPAIR'/ / PUMP REPLACEMENT /7 J <br /> Other �•. ,_ <br /> I <br /> CE TO NEAREST: SEPTIC TANK SEWER LINES -PIT PRIVY <br /> SEWAGE DISPOSAL FIELD ' CESSPOOL/SEEPAGE PIT f <br /> PROPERTY LINE - PRIVATE DOMESTIC WETIL PUBLIC DOMES—TIC O WELL ' <br /> # <br /> THER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> I atrial Cable Too! Dia. of Weil Excavation <br /> Domestic/private Drilled Dia, of 'Well Casting i <br /> Domestic <br /> /Public Driven Gauge of Casig _ _ - <br /> __I rrigation Gr e1 ;Pack '�' bep th of Grout eal <br /> Carhodic'Pro"lection �` W nary` `TyF -(;r6- t` - <br /> Disposal Othero . <br /> Other Informatin �- <br /> Geophysical Surface Seal Installed B : <br /> t <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: State Work Done <br />'r <br />' DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth , <br /> a <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 DAIS <br /> after completion of my work on a new well,'-`I'"�aii2"`furnish_..the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify thein- before putting the"`w`ell i.n use. The above`, <br /> information is true to he best of my knowledg-p and belief. I WILL CALL FOR A GROUT IN5PECTIOIV-4. <br /> PRIOR TO 0 ING D FINAL INSPECTION. �+ <br /> SIGNED , <br /> TITLE <br /> (DRAW ,PLOT PLAN ON REVERSE SID <br /> FOR_,DEP,ARTMENT USE ONLY, <br /> PHASE I . ,.f <br /> APPLICATION ACCEPTED BY DATE / 7g- <br /> ADDITIONAL COMMENTS: ,•' ; <br /> PHASE II GROUT INSPECTION <br /> INSPECTION BY °• ' PHASE III FINAL INSPECTION <br /> DATE INSPECTION BY,`. / DATE ' <br /> E H 1426 Rev. 1-74 ' <br /> v- 7a <br />