Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF,:OFFICE USE: v 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -K-idQ7, <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -7.3-•-11 <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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION _��Q (t� rTwy �a2 ob- CENSUS TRACT <br /> Owner's Name ��� ��Q _� Phone ,T68 68 <br /> - / 7 <br /> \ ti , <br /> Address o�.�,02 [1� [�pa-,-y 2��1/� City ' <br /> Contractor's Name ��''. /�7r�� /.�,._I_�� License I129��ef Phone <br /> {_ TYPE'OF WORK (Check): NEW WELL DEEPEN/� RECONDITION f-1 DESTRUCTION /-] <br /> ' PUMP INST CATION /—/ PLW REPAIR-/—/—PUMP REPLACEMENT /-T <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES Zro- PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> U <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation / <br /> 4/• Domestic/private Drilled Dia. of Well Casing R <br /> i Domestic/public Driven Gauge of Casing Sc2 <br /> ! Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout p <br /> t'• Other Other Information <br /> - t \ <br /> PUMP INSTALLATION: Contractor ACri^o aS - <br /> Type of'Pump H.P. 2 <br /> �• PUMP REPLACEMENT: / / State Work Done - - <br /> PUMP '2EPAIR: a / / SEa[e Work Done - <br /> i <br /> j)FITRUCTION OF WELL: Well Diameter _• AppYo'ximat2"Depth^--•--=--• <br /> Describe Material and Procedure i <br /> i <br /> iI 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 E <br /> WELL DRILLERS REPORT of the well and notify'-them before putting the well in use. The above <br /> E information is true to the best of my knowledge and belief. <br /> SIGNED .4 4q - TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> { PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: _ <br /> PHASE II GROUT INSPECTION----- -- PHASE III/FINAL INSPECT 0 <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 5/731M <br />