Laserfiche WebLink
{ E <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE;OFFTCE USE: 601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 j <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> t - <br /> (Complete In Triplicate) <br /> 3 <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 Sart Joaquin, <br /> County Ordinance No. 1.862 and the Rules and Regulations of the San Joaquin L cal Health District. <br /> j]�� �l 7�a i°r <br /> JOB ADDRESS/LOCATION L/� r (r'� C C�LI r- CF Us TRACT <br /> l fes' o <br /> Owner`s Name �--!��19 0 C' r � � a-14 p Phone <br /> Address .9 rG v .12 i.ty <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/ J RECONDITION I I DESTRUCTION <br /> PUMP INSTALLATION J I SUMP REPAIR / / PUMP REPLACEMENT <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY R- <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PTT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool. {Dia: of Well Excavation <br /> Domestic/private Drilled Dia.' of,Well Casing ; <br /> Domestic/public\\-,,.a. ,. Driven --_.. V Gauge of Casing <br /> Irrigation :`Gravel Pack Depth of Grout Seal. <br /> Other ..Rotary 3t,.jType of Grout <br /> Other ---Other Information ' <br />� PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> � i H <br /> a PUMP REPLACEMENT': u/ / S k`ate Work-D"ond"'"--" <br /> rt rte- �. � ,..�._ _ _ -• + � ��~' � -.... _ "`°fi � ' <br /> PUMP UPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter A proximateD <br />' Describe Material and Procedure . f r r ie <br /> d^s / Sir �., cv ' <br /> I hereby agree to comp y with all laws an regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well 'construction. f 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 iri use. The above <br />`f information is true. to the best of my knowledge and belief. <br /> SIGNED EUTITLE P <br />'r+ <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br />�7 PHASE I <br /> APPLICATION ACCEPTED .BY r DATE ¢- <br />'` ADDITIONAL COMMENTS: <br /> t PHASE II GROUT INSP CTION PHASE II NAL INSPEC Old_ <br /> INSPECTION BY DATE INSPECTION B <br />{I - CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL IN. CTION 3, 2� <br /> 5 7 3 iN �'`. <br />