Laserfiche WebLink
�N <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT -� �t <br /> i Y,T * ° ) <br /> For, OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> f <br /> Telephone: (209) 466..478l ate. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT - Permit No.,"_�3�_�,�I <br /> THIS PERMIT EXPIRES I YEAR FROM DATE 'ISSUED Date Issued <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 Joagtalt <br /> County Ordinance No. A62 and the Rules and Regulations of the Sart Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION la a ?-,uc,lt_ CENSUS TRACT iI <br /> EEK <br /> Owner's Name _ � - -- - Phone 1 8`.T-FZ /60".+v— <br /> Address d G oza (a" Cityaoa. 4- , q Lo <br /> Contractor's Name s ^si <br /> LiCen5e '�`� J <br /> Phone <br /> f TYPE OF WORK (Check): NEW WELL 0 DEEPEN / / RECONDITION /_/ DESTRUCTION /-77 <br /> PUMP INSTALLATION -/ / PUMA REPAIR '/ / PUMP REPLACEMENT /? <br /> Other / / <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 Z=— Cable Tool Dia. of Well Excavation <br /> —. Domestic/private Drilled Dia. of We11 Casing " <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 <br /> PUMP INSTALLATION: Contractor f� '^� �3r •, } <br /> Type of Pump ._ � .6- H.P. �S <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'REPAIR: / / State Work Done i <br /> �t PF-TRUCTION 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 4 work on a new well, 1,.will furnish the.-San Joaquin Local Health District a <br /> WELL DRILLERS REPORT 0 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 /> 't SIGNE�- siC �,_r,cx_ti._;, TITLE <br /> �df�--� (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I � / �77 -, <br /> APPLICATION ACCEPTED .BY `.DATE 6 ;?�/'_/3 <br /> ADDITIONAL COMMENTS: <br /> PHASE II'[GROUT INSPECTION 'PHASE III/FINAL INSPECTION <br /> INSPECTION BY ,:Ip DATE 7/) - T.3 INSPECTION,^BY DATE <br /> } CALL FOR A GROUT .INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. j$QO , <br /> E H 1426 <br />