Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: �01 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 124,q D1/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued f jz, <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> 4 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 � �� <br /> 7y �y��i CENSUS TRACT 8 4-7 <br /> Owner's Name Phone z-1G _-_7863 _ <br />' Address 3 A/ /V City S TI('N <br /> F Contractor's Name License # /fit roc{Phone 7q5-Ios'L <br /> I � <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /_% RECONDITION /_7 DESTRUCTION <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK G SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial }� Cable Tool Dia, of Well Excavation 1k <br /> X Domestic/private '` Drilled Dia, of Well Casing S - <br /> Domestic/public Driven , Gauge of Casing 12- <br /> Irrigation <br /> 2Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout ,, T � <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor ' 2 S_7 4 / <br /> Type of Pump H.P. 3 <br /> t PUMP REPLACEMENT: / J State Work Done ` <br /> PUMP REPAIR: J / State Work Done <br /> a <br /> ESTRUCTION 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 is true to the best of my knowledge and belief. <br /> s <br /> SIGNED TITLE <br /> P .. (DRAW Pt= PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I � �, � / <br /> APPLICATION ACCEPTED BY ,, F DATE <br /> ADDITIONAL COMMENTS: / <br /> INSPECTION <br /> III .OUT E FINAL <br /> INSPECTION BY <br /> PHASE II G INSPECTION PHASE <br /> INSPECTION BY DATE <br /> _ <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br />' E H 1426 � " 7/72 1Mi i� <br />