Laserfiche WebLink
a SAN JOAQUIN LOCAL HEALTH DISTRICT i <br /> >v:OF..•OFFICE USE: 1.601 E. Hazelton Ave., Stockton, Calif. �a <br /> Telephone: (204) 4666781 <br /> APPLICATION FOR WEIyL CONSTRUCTION OR PUMP PERMIT Permit No. 7S/ .2 ,S-3 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 /> " LIX071t...& <br /> JOB ADDRESS/LOCATION '/ pCENSUS TRACT <br /> w... S <br /> ,Owner's Name Phone <br /> Address � / 1 . !! City, ' `' a,4 - �A <br /> Contractor's Name t License <br /> 3 <br /> 1 <br /> TYPE OF WORK (Check) : NEW WELL � k:�f EEPEN %/ RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION_,& PUMP REPAIR / / PUMP REPLACEMENT /—T <br /> Other / / <br /> 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DIS SAL FIELD CESSPOOL/SEEPAGE PIT OTHER fil`li <br /> INTENDED USE TYPEPF WELL CONSTRUCTION SPECIFICATIONS ot, <br /> Industrial Cable Tool Dia. of Well Excavation <br /> ,,.Industrial <br /> Domestic/private '" Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing L <br /> Y Irrigation Gravel Pack Depth of Grout Seal j7V <br /> Other Rotary Type of Grout <br /> Other Other In _. <br /> i <br /> 1 <br /> PUMP INSTALLATION: Contractor <br /> Type of.Pump --., ,..�i..._, _ _ - H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'PAIR: / / State Work Done <br /> ,DF'P-TRUCTION 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 xe best of my knowledge and belief. <br /> SIGNED TITLE d9 /1 eO <br /> (DRAW'PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I I <br /> APPLICATION ACCEPTED -BY �' DATE <br /> ADDITIONAL-COMMENTS: <br /> PHASE II GROUT INSPECTION PM4& III/F AL 4NSPECTIO <br /> INSPECTION BY DATE 7L INSPECTION B ATE <br /> CALL FOR-A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br />