Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOt. OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <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 Joaqui <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION _/Lz���- .1 CENSUS TRACT ry <br /> Owner's Name X111'k,-. A/1-et,_ /C. Phone <br /> Address — /i �i,e-j� . Le-e-- cr ��i� ��� City <br /> Contractor's Name Aplq,�le /�jLyTrp Y License 0 Phone,/e6 -e),;j <br /> TYPE OF WORK (Check) : NEW WELL QZ( DEEPEN /_/ RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION Y PDMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK/oo SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS Q <br /> Industrial Cable Tool Dia. of Well Excavation <br /> - Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other _ Rotary Type of Grout <br /> Other Ocher Informations S <br /> PUMP INSTALLATION: Contractor ,p <br /> Type of Pump _ R.P. _:z _ <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP UPAIR: / / State Work Done <br /> ,DF�TRUCTION 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 wellconsl'ruction. 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 REPORJ of the well and notify them before putting the we use. The above <br /> information to the/` f my knowledge and belief. <br /> SIGNED .«'tl��ri .�CE�J TI <br /> -w _ (DRAW PLOT PLAN ON REVERSE 5 <br /> FOR DEPARTMENT USE ONLY / <br /> PHASE I q <br /> APPLICATION ACCEPTED BY DATE 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE 1I GROUT INSPECTIO PHASE Z /F AL I PECTION <br /> INSPECTION BY� DATE INSPECTION BY DATE <br /> - CALL FOR A GROUT INSPECTION PRIG' TO G OUTING AND FINAL INSPECTION. <br /> E H 1426 5/731M <br />