Laserfiche WebLink
SAN JOAQULN_,,LOCAL HEALTH DISTRICT I <br /> F'OR QFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7/1 S q-rV <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued T 7� <br /> „_ (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 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 _ a CENSUS TRACT <br /> K <br /> Owner's Nance <br /> Phone R-, <br /> Address City <br /> r <br /> Contractor's Name �Lc License 11. s 01p Phone <br /> - C7 y <br /> TYPE OF WORK (Check) : NEW WELL / EEPE�N� �/ " RECONDITION /� DESTRUCTION <br /> PUMP INSTALLATION f-7 PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other / / . T <br /> DISTANCE TO NEAREST: SEPTIC TANK EWER L:�dES.� IT PRIVY <br /> SEWAGE DISPOSAL FIELD �ESSPOOL/SEEPAGE PIT &_OTHER (n <br /> INTENDED USE \ TYPE OF WELL CONSTRUCTION SPECIFICATIONS V ` <br /> Industrial `. Cable Tool Dia, of Well Excavation <br /> =/Aomestic/private , Drilled Dia, of Well Casing S r/ <br /> Domestic/public . _ Driven Gauge of •Casing <br /> _"Irrigation Gravel Pack Depth of Grout Seal <br /> Other otary Type of Grout /y- <br /> Other Other Information i <br /> PUMP INSTALLATIONo Contractor • :�- `- � <br /> Type of Pump H.P. `. <br /> PUMP REPLACEMENT: / / State Work�Doine+ <br /> PUMP REPAIR: / / State Work Done- <br /> ' _ <br /> i Approximate Depth �� <br />,DESTRUCTION OF WELL: Well Diameter ' <br /> , <br /> Describe Materia and Procedure .i <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 /> infor on is true to the of m knowledge and belief. <br /> i <br /> SIGNED 1-tL _ TITLE L�} <br /> LOT- PLAN ON REVERSE SIDE <br /> 1 FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE ��'� <br /> ADDITIONAL COMMENTS <br /> PHASE II GROUT INSPECTION PHASE III INAL INSPECTION � <br /> INSPECTION BY DATE 1 -� <br /> '1 I-)�°{ INSPECTION BY DATE <br /> CALL FOR AqkOUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7172 1M r <br /> .#;' <br />