Laserfiche WebLink
` s ' <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF_:OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> �. Telephone: (209) 466-6781 p <br /> t, APPLICATION FOR WELL CONSTR�CT�IBN:;AR PrUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1. YEAR FROM DATE ,ISSUED Date Issued <br /> Ll <br /> (ComplAe fn 'Tri1plicgte-)- <br /> Application. is hereby made to the San Joaquin Local Health Df-strict f-or- a permit to construct <br /> and/or install the work herein described. ' This application is made in compliance with San Joaquin <br /> CountyN Ordinance .No.. 1862.'and the I-Rules ,and Regulations of the San Joaquin Local Il. . lth District: <br /> JOB ADDRESSJLOCATIONL ' <br /> OSS C � S �� ivs5 TRACTs�2-sa-�� <br /> Owner's Name r.. Phony <br /> Address <br /> s J L � city <br /> 4� i <br /> Contractor's Name <br /> ` License 4� ®$ Phone <br /> TYPE OF WORK (Check): NEW WELL-'/-7 DEEPEN '/ I RECONDITION / J DESTRUCTION I`T <br /> P#MP 1N$TALLAT-ION Pubo REPAIR J / PUMP REPLACEMENT I T <br /> Gther <br /> DISTANCE TO NEAREST:, SEPTIC TANK SEWER LINES PIT-PRIVY � <br /> S WAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT i OTHER <br /> INTENDED USE TYPE OF WELL \�, CONSTRUCTION SPECIFICATIONS `= <br /> Industrial Cable Tool Dia. of"Well Excavation ` <br /> Domestic/private Drilled_, , Dia. of Well Casing <br /> Domestic/public Driven ' Gauge of'Casing y" <br /> Irrigation Gravel Pack Depth of Grout- Seal M <br /> Other Rotary- Type of Grout <br /> other Other Information- <br /> PUMP INSTALLATION: Contractor Lv <br /> P. 1 <br /> TYPe 'of Pump- •' v %3 M�G�S f H <br /> PUMP REPLACEMENT: //;;,- State Work, bode <br /> PUMP 'tIR: State Work Done <br /> .DF-,TRUCTION OF WELL: Well Diameter Approximate Depth , <br /> Describe Material and Procedure <br /> I hereby gree to comply with all laws and regulations of the San'Joaquin Local Health District <br /> and the Stat6 'of California pertaining to or regulating well''construction. Within ;FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of th �.we anmd4,,notify them before putting the well in use. The above <br /> information- is, true to th be of my a4ledge, an&Velief <br /> F <br /> TITLE' <br /> SIGNED y <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> e"� FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION_ACCEPTED,_$Y DATE G <br /> ADDITIONAL COMMENTS - <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> - CALL FOR A GROUT INSPECTION PRIOR.TO GROUTING AND FINAL INSPECTION. <br /> .. <br /> F. H 1426 ,r:� <br />