Laserfiche WebLink
4. 'OAQUIN LOCAL HEALTH Dlo , <br /> iuc <br /> rm, <br /> FOR (YFF E USE: 1601 E_ . HazelLon V/ Ave. , Stockton, Calif, <br /> Telephone : (209) 466-6781 I <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Permit No. ;;:.0- 1034r/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued z1f <br /> (Complete In Triplicate) 4/7_ <br /> 01 <br /> a perlt 'to construct <br /> Application is hereby made to the San Joaquin Local Health District r. f- <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 20, -;)COc-OS-aoc, CENSUS TRACT <br /> Owner's NameC'4rzn„gvPhone <br /> Address a7ois7 <br /> C i t y <br /> Contractor's Name <br /> /Vt)-a C_ License # Phone <br />. TYPE OF WORK (Check) : NEW WELL /7 DEEPEN jam/ RECONDITION /_7 DESTRUCTION 1-7 <br /> PUMP INSTALLATION / T—PUMP REPAIR REPLACEMENT— /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PITPRIVY <br /> SEWAGE DISPOSAL FIELD <br /> CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTIONSPECIFICATIONSIndustrial Cable Tool Dia. of Well Excavation 6 " /s Is-4 <br /> Domestic/private Drilled Dia. of Well Casing e. <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> C-i <br /> Type of Pump H.F. <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: State Work Done <br /> PESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with alllawsand 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 /> SIGNEDl3 TITLE 'n 0")Ij(_�-rZ <br /> (DRAW PLOT PLAN ON REVERSE SIDE)— <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASF&, II_I_/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> .TIO <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTIO <br /> _E H 1426 V , 7/72 IM <br />