Laserfiche WebLink
- <br /> �� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> [-FOR OFFICE USE: .1601 E, Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) 466-6781 ?�a� l <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No 7 -acex <br /> THIS PERMIT EXPIRES1 YEAR FROM DATE ISSUED <br /> Date Issued .OW~Jy <br /> ( <br /> Application is hereby made to the San Joaquin Local health District for a <br /> permit <br /> and/or install the work herein described. This application is made twithnSanuJoaqui <br /> Co ty_ d hence p�8 2 a d the itt compliance Rules d Regul ;igns Of the San Joaquin Local Health District. <br /> JOIE ADDRESS/LOCATION ,�-[/ <br /> l d ATSUS TRACT <br /> Owner's Name <br /> Phone 3(o 7-2 276 <br /> Address <br /> City ' <br /> i <br /> Contractor's Name ¢ <br /> License 0/4-11?7 j Phone p�-3, <br /> TYPE OF WORK (Check) : NEW WELL ( DEEPEN /-7 RECONDITION /-7 DESTRUCTION-/-7- <br /> PUMP INSTALLATION 6;V PUMP REPAIR / / PUMP REPLACEMENT 1-7Other /-7 <br /> _ — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> SEWAGE DISPOSAL FIELD _ CESS�POOL/SEEPAGE PIT d <br /> /� OTHER <br /> 1Td&E FCL �� <br /> INTENDED USE TYPE OF WELL � <br /> Industrial CONSTRUCTICable Tool. Dia, of Well—Excavation <br /> Domestic /,�. � <br /> /private Drilled Dia, of Well Casing U� <br /> Irrigation <br /> Driven Gauge of Casingr,;�Jq, <br /> Other <br /> Gravel Pack <br /> Other —�— Depth of Grout 5ea1„$"p <br /> ----- Rotary Type. of Grout <br /> Other Other Information , <br /> PUMP INSTALLATIO14: Contractor <br /> Type of pump <br /> --,----- ►: oma, II.P. <br /> PUMP REPLACEMENT: I State Work Hone f <br /> PUMP REPAIR. / / State Work Done <br /> ,PESTRUCTION Or WELL: Well Diameter _ , <br /> Describe Material and Procedure -- Approximate Depth <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 constriction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, T Will furnish the San Joaquin Local Health Uistriet a <br /> WELL DRILLERS REPOIt7' of the well and notify them before putting the well in use. The above <br /> information is true to the best of MY know edge and belief <br /> SIGNED <br /> - �����_{DRAW PLOT PLAN ON REVF,R5E STDE�. _ t <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I - - <br /> APPLICATION ACCEPTED BY VQ ,terrai <br /> ADDITIONAL COMMENTS: DATE j- �/ <br /> PHASE II GROUT INSPECTION PHASE 11 -1F1 AL INSP�,TN <br /> --------- <br /> INSPECTION BY __. DATE �_, ,�+� INSPECTION 13Y <br /> CALL. FOR A GROUT XNSPECTION PRIOR TO GROUTING AND FINAL (NSPECTION. DATE <br /> E R 7,426 <br /> _� .— — ��-----�— 7/72 :ire <br />