Laserfiche WebLink
- ALJ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit 130. Tom-/S�/a <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> �- (Complete In Triplicate) 00 - 2(p4A, fa r�3 <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 /> � cX� .lv�CENSUS TRACT <br /> JOB ADDRESS/LOCATION <br /> �./Jc-1�2 '� '�- �- <br /> Owner'a Name L fr Phone16-1-6 3 j l` <br /> 3 city ` <br /> Address -� <br /> Contractor's Name <br /> License �3?j Phone <br />,TYPE-.0F.WORK_ (Check) NEW W LL /� AEEPEN /� RECONDITIONS/�. DEST.RUCTION /rT <br /> PUMP INSTALLATION / / PUMP REPAIR /k/ PUMP REPLACEMENT -7 <br /> Other /_7 <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 41 <br /> Industrial Cable Tool Dia. of Well Excavation <br /> , Domestic/private Drilled Dia. of Well Casing <br /> ,k- <br /> Domestic/public Driven . Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout .� T <br /> f Other Other Information <br /> PUMP INSTALLATION- Contractor H.P. 1 <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work e <br /> PUMP REPAIR: : .AC/ <br /> State Work Done , <br /> },. <br /> '""'�' ",."-- AppXoxlmate Depth <br /> ESTRUCTION OF WELL: Well.,�Diameter <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 o€ 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 /> TITLE r <br /> SIGNED <br /> (D PLOT PLAN ON REVERSE SIDE <br /> DEPARTMENT USE ONLY <br /> PHASE I DATE - Y <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GR IHSPE TI _ PHASE III FINAL INSPECTION <br /> INSPECTION BY '-DATE INSPECTION BY ,1. DATE •/ a <br /> CALL FOR GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> R 7/72 1M <br /> E H 1426 <br />