Laserfiche WebLink
° SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF.rOFFICE USE: 1601 E. Hazelton Ave., Stockton, Calif. ¢ <br /> Telephone: (209) 466-6781 7T� <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) I' <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct u; <br /> and/or install the workl!hereiu described. - This application is made in compliance with San Jbaquin <br /> County Ordinance No. 18.2 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION o 0 h/ouiAk D IZ d CENSUS TRACT <br /> 0 . <br /> Owner's Name /3/iwNo �N /tGh11J/ /3R�s - <br /> Phone 4163-97170 <br /> Address <br /> 000 N/A2P lZ /) City S 'TkAl G/fti!� <br /> License #y PhoneYiE[ 9fl3`� <br /> Contractor's Name "L <br /> TYPE OF WORK (Check): .1.NEW WELL/ I DEEPEN/7 RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PLTYP REPAIR _Y/ PUMP REPLACEMENT — <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/privateDrilled Dia. of Well Casing <br /> Domestic/public Driven - Gauge of Casing <br /> Irrigation Gravel Pack i Depth of Grout Seal <br /> Other ,% Rotary Type of Grout <br /> q Other I Other Information <br /> PLW INSTALLATION: Contractor <br /> H.Y.. <br /> Type of Pump jII <br /> PUMP REPLACEMENT: / State Work Done <br /> / <br /> iState Work Done 7�� hf <br /> PUMP 'tEPAIR: <br /> ( ,DFRTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> } Describe Material and Procedure <br /> I hereby agree to co ly with all laws and regulations of the San Joaquin Local Health District <br /> j and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> on of my work on a new well, I will furnish the San Joaquin Local Health District�la <br /> after completi <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is true t�O the best of my knowledge and belief. <br /> TITLE <br /> § SIGNED .w-�- /�..u. 1� SY' l -�i�e- <br /> i Q (DRAW P P PLAN ON REVERSE SIDE <br /> ' . FOR DEPAK5FN USE ONLY <br /> PHASE I DATE - 5r,/7-3 <br /> APPLICATION ACCEPTED BY t <br /> J ADDITIONAL COMMENTS: pig /FIN INSPECTION 0 <br /> PHASE II GROUT INSPECTION INSPECTION B DATE/;z <br /> INSPECTION BY p DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. 5731M <br /> R H <br /> 1106 - -- <br />