Laserfiche WebLink
SAN JOAQUIN LOCAs. HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Razelton Ave, , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No./3� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3-p2,7 <br /> P: � (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 �e .2 � c�� u �r�d �]tlk �I• taj! &ENSUA TRACT 0 - 07p pf <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Name License #,A?!32;5rPhone 1_-7674 <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN /7 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR /1(/ PUMP REPLACEMENT /-7 i <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of We11 Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> -'-;-�- Other Rotary Type of Grout <br /> _UA arm b Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of PumpH.P. ~ <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: State Work Done j 0 - <br /> ,)EST_RUCTION 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 kn wled-g nd belief. <br /> SIGNED TITLE <br /> RAW PLOT PLAN ON 1MVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br />� APPLICATION ACCEPTED BY DATE 1_22 -13 <br /> ADDITIONAL COMMENTS: <br /> PRASE II GROUT INSPECTION PHASE 4II4FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY � DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M 1�-�. <br />