Laserfiche WebLink
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 No. � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3-/g 7S— <br /> (Complete In Triplicate) 0� rf0 <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 _3.0t4T1 I o o A,e,�:E ti­_� 4 z R CENSUS TRACT <br /> Owner's Name / C, L _ L Phone <br /> Address G.'��� City <br /> Contractor's Name EiJA) �l UTAJ 2-f111112 [7(J, License # Phone .-WIY7/ <br /> TYPE OF WORK (Check): NEW WELL /_7 DEEPEN / / RECONDITION /_7 DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR _&7/ PUMP REPLACEMENT /_7 <br /> Other / / <br /> DISTANCE TO NEAREST; SEPTIC TANK41 <br /> SEWER LINES PIT PRIVY N ' <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER N <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 <br /> Irrigation Gravel Pack Depth of Grout Seal *t <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> a <br /> Type of Pump 11G--,e 6 L - L H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR- State Work Done pu L c Ei7 punw p ) Rf 1�c-e.o tv r� i-t)6 <br /> -P.ESTRUCTION 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 TITLEv- <br /> (DRAW PLOT PLAN ON REVERSE SIDEKZ <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY C - DATE <br /> ADDITIONAL COMMENTS: �. <br /> PHASE II FROUT INSPECTION42L4r7 PHASE III/FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />