Laserfiche WebLink
a i <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR• PUMP PERMIT Permit No.7 ,f2,p <br /> THIS PERMIT EXPIRES_1 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 / y- �yj r�.r ENSUS TRACT 0('7- fro--02 <br /> Owner's Name d L d0 J� Phone <br /> Address lL14. 1 0(2ck/V-R c� - / A-,*,.aa d City /-1-h7.f�� <br /> i Contractor's Name ( _ v J� License #I 12 7 1 Phone 4 <br />` TYPE OF WORK (Check): NEW WELL /!�-7- DEEPEN /=T --RECONDITI-ON_=/_7 -DESTRUCTION- /_7 <br /> s PUMP INSTALLATION / / PUMP REPAiRf PUMP REPLACEMENT <br /> J Other <br /> 41 <br /> DISTANCE TO-NEAREST: SEPTIC 'TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER M <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> E Domestic/private -Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing T T <br /> - Irrigation Gravel-Pack _Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other `- - Other Information <br /> PUMP INSTALLATION: Contractory /?.� _ <br /> - - / -- <br /> A Type of Pump - - �� 1� b� /'"/4 E H.P. 0 <br /> t <br /> PUMP REPLACEMENT: / / State Work Done ~" <br /> PUMP REPAIR: State Work Done <br /> ,RESTRUCTION 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 /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �� <br /> APPLICATION ACCEPTED BY � e�� � ' ^•� DATEQ' ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE INSPECTION . <br /> INSPECTION <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. - <br /> .. E H 1426 7/72 1M <br />