Laserfiche WebLink
r SAN JOAQUIN LOCAL HEALTH DTSTRICT <br /> E, <br /> OFFICE USE: =. p.. ° 1601 E. Hazelton' Ave. ' <br /> Stockton, Calif. <br /> Telephone': (209) 466-6781 ` <br /> E APPLICATION FOR WELLCONSTRUCTIONOR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED , Date Issued3. <br /> J (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 incompliance with San Joaquin j <br /> County Ordinance No. -1862 and the Rules and Regulations of the San Joaquin Local Health District. <br />' s,rlL 5-77n.l- 0- `1- 'l3'3'je'`-`G A-�,�r.. p ,� a 4 <br /> JOB ADDRESS/LOCATION P All� Nadi (rIwn/C CENSUS TRACT <br /> Yin --7 <br /> Owner 1c�1 <br /> ' Phone <br /> ,5 Name <br /> AddressCity �-!Gey' '✓ i <br /> Contractor's Name j_/�IV S 4?0-v5 6*-71-11- P License ftl7.f3 k) Phone <br /> k ' <br /> TYPE OF WORK (Check) : NEW WELL/ J DEEPEN/ / RECONDITION/-7 DESTRUCTION /-7 <br />'• PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other / J <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY A <br /> SEWAGE. DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS [fi <br /> Industrial L Cable Tool Dia, of Well Excavation <br /> G Domestic/private f Drilled Dia. of Well Casing <br /> Domestic/public i Driven Gauge of Casing <br /> ^ 1,!,' Irrigation 3 Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> ! Other Other Information ' <br /> F <br /> E <br /> PUMP INSTALLATION: Contr a ctor �: <br /> Type of Pump pff2l,^�5 H.P. / <br /> U LL �J73 jj' ,K-G2 vg S <br /> PUMP REPLACEMENT: � State Work Dane � _ S <br /> PUMP REPAIR: / / State Work Done <br /> ,DESTRUCTION 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 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 /> SIGNED ` _ _ 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 /> PHASF{,II GROUT INSPECTION PHA I FINAL INSPECTION <br /> f INSPECTION BY _ DATE INSPECTION BY DATE <br /> 1 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECT N. � <br /> E H 1426 4/72 <br />