Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT -T �. ® 0 <br /> F R OFFICE _USE: .1601 E. Hazelton Ave. , Stockton, Calif. A <br /> i 'Telephone-; (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> y 7"-3 X00 Lr� �ii <br /> -V to f <br /> THIS PERMIT EXPIRES 1- YEAR FROM DATE .ISSUED Date Issued J�3 <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 Joaquin! <br /> County Ordinance No. 1862 anis the Rules' and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> Owner's Name - <br /> � -:Phone 9-3/- 460/ � <br /> Address [ City ' <br /> Contractor's Na <br /> meL9l-13 l.� L-G /LG <br /> „ /�'. _ License .#1 Phone 1,0L%_ <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /7 RECONDITION /? DESTRUCTION /_ <br /> PUMP INSTALLATION / /�—PUMP REPAIR REPLACEMENT <br /> Other ,% / <br /> DISTANCE TO NEAREST: SEPTIC TSEWER LINES PIT PRIVY <br /> SEWAGE .DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> _ Industrial X Cable Tool Dia, of Well Excavation <br /> C� Domestic/private Drilled Dia. of Well Casing ' <br /> Domestic/public 1 Driven Gauge of Casing <br /> Irrigation t Gravel Pack Depth of Grout Seal �tea' � <br /> Other ! Rotary Type of Grout �4 <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor IV Z s`7 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / <br /> State Work Done <br /> I <br /> PUMP REPAIR: State Work Done f <br />,pES_TRUCTI.0_N OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> � e <br /> I <br /> I hereby agree to comply with- all laws and regulations of the San Joaquin Local Health District <br /> and the State of California peirtaining 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 bes`,t of my .knowledge and belief. <br /> SIGNED �Zee <br /> ITLE <br /> (URAW PLOTON REVERSE SIDE _ <br /> FQR DEPARTMENT USE ONLY _ <br /> PHASE I <br /> APPLICATION ACCEPTEOBY ., DATE <br /> ADDITIONAL COMMENTS p,PPECTION PINSPECTION <br /> INSPECTION BYE Z INSPECTION BY DATECALL FOR A TPRI R T GROUTING AND FINAL IN ON ` <br /> E H 1426` 7/72 1M <br />