Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> IOF..O1,IICE USE: 1601 E. Hazelton Ave., Stockton, Calif. <br /> r Telephone: (209) 466-6781 <br /> ,APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit Na. 7 1 -�D6 <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 Joaquin; <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. , <br /> JOB ADDRESS/LOCATION `-"•L'! °p _ _ CENSUS TRACT <br /> Owner's Name U� r Pl -- Phone <br /> _ <br /> Address cj ,� C�! O A city . .J� l v <br /> ,�I - <br /> Contractor's Name License 4� i'hppe /pP` <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION /—/ DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR ,/ / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> I SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS C� <br /> Industrial Cable Tool Dia.. of Well Excavation 1 <br /> r Domestic/private Drilled 'Dia. of Well Casing e. <br /> Domestic/public Driven Gauge of Casing C <br /> Irrigation Gravel Pack Depth of Grout Seal to ` <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor > , <br /> Type of Pump H.P. <br /> F <br /> f - ' <br /> PUMP REPLACEMENT: /�j State Work Done <br /> PUMP. UPAIR: / / State Work Doke <br /> A DFRTRUCTION OF WELL: Well Diameter Approximate Depth <br />:.� Describe Material and Procedure <br /> Z hereby agree to comply with all laws and regulations of._the San Joaquin Local Health District <br /> 11 and the State of California pertaining to or regulating well"construction. Within FIFTEEN DAYS <br /> after completion of my work on a riew 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 /> E> informati s rue to the best of'my owledge .and belief.. <br /> --, � � <br /> SIGNED TITLE - <br /> ;! RAW PLOT PLAN ON REVERSE SIDE)'AD ' <br /> ` FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE /a <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY /w, DATE INSPECTION BY DATE /- - 7 2 <br /> -ter--t-- - - ._"��// C �. <br /> 4� CALL FOR A GROUT INSPECTION PRION TO- GROUTING AND FINAL INSPECTION. <br /> 5/731M <br />