Laserfiche WebLink
r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 0 .' OF1 ICI IISE: 1601. E. Hazelton Ave. , Stockton, Calif. <br /> W Telephone: (209) 466-6781 <br /> X IL APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE. ISSUED Date Issuedi6-_ � <br />` (Complete In Triplicate) �N <br /> f Application is hereby made to the San Joaquin Local Health District ANNED construct <br /> and/or install the work herein described. , This app-iication is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules an lations of the San Joaquin Local Health District. <br /> .708 ADDRESS/LOCATION 5 S Aj,, CENSUS TRACT <br /> Owner's Names . Phone R' k_-42,i_, <br /> Address City ' . <br /> Contractor's Name License Phone <br /> . . r <br /> TYPE OF WORK (Check) : NEW WELL/ J DEEPEN '/ / RECONDITION_ /�/ DESTRUCTION /_ <br /> PUMP INSTALLATION /7 PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK EWER L RS IT PRIVY <br /> SEWAGE DISP SAI. FIELD ESSPOOL/SEEPAGE P T4� OTHER ---- <br /> U <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation l/ ` <br /> I omestic/private Drilled `Dia. of Well Casing G /P �J <br /> I Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout S <br /> Other otary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor 0 1- <br /> Type of Pu b--y .P / <br /> PUMP REPLACEMENT: / / State Work bone <br /> OvVnrf_zfi Wi 113fjND0r4 Own! WCLL \k, <br /> - <br /> PUMP UPAIR: / / State Work Done " <br /> DFCTRUCTION OF WELL: Well Diameter Approximate Depth <br /> f <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 /> 4 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 /> inf rmation is true to the best of my knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> DEPART- MFNT USE ONLY <br /> PHASE I 5-ql <br /> APPLICATION ACCEPTED—AY (/L�LINDTI DATE <br /> ADDITIONAL CONI ENTS: <br /> PHAS II OUT INSPECTIO P II AL INSPECTIO <br /> INSPECTION BY f � _ DATE INSPECTION BY/ geZ DATE, <br /> CALL FOR A GROUT INSPECTION PRIOR 'CLQ GROUTING AND FINAL I TION. <br /> E H 1426 _ 5/731M <br />