Laserfiche WebLink
w 6� L <br /> SAN JOA UIN LOCAL <br /> Q HEALTH DISTRICT <br /> FOF.;OFFICE USE: 1601 E. Hazelton. Ave. , Stockton, Calif. <br /> Telephone; (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit Na. s1hJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 1p_,7-1- -v <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 applic-a h s ma e n nce with Saxe Joaquin <br /> County Ordinance No. 1862 an{d the Rules and <br /> geof an�Toaquft �thea.. ealth District. <br /> JOB ADDRESSILOCATION <br /> as�US T T <br /> i <br /> Owner's Name _ �'.�^�� h ne <br /> Address 1 � _ <br /> City <br /> Contractor's Name Licensel> Phon <br /> 1 '`�.. . <br /> TYPE OF WORK (Check) : NEW WELL — DEEPEN ./� RECONDITION /_/ DESTRUCTION /-7'UMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES �f� PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> _ V <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS V <br /> Industrial ; Cable Tool Dia. of Well Excavation <br /> —7 Domestic/private i Drilled Dia. of Well Casing <br /> Domestic/public. 1 Driven Gauge of Casing <br /> Irrigation1 Gravel Pack Depth of Grout Seal - r <br /> Other _ - .�- Rotary Type of Grout <br /> 4Q4 9 44 <br /> Other Other Information , <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: /-7 State Work Done <br /> PUMP UPAIR: <br /> State Work Done , <br /> ,DFCTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> w <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) w <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I i <br /> APPLICATION ACCEPTED .BY DATE <br /> ADDITIONAL COMMENTS: - <br /> PHASE GROUT INSPECTION P T /FINAL INSPECTION <br /> INSPECTION BY W .DATE 0�.. ��1�1V1_ INSPECTION BY DATE <br /> . CALL FOR A UT INSPECTION PRIOR TO GROUTING AND .FINAL INS ION. <br /> E H 1426 <br />