Laserfiche WebLink
s SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> POL OFFICE USE: Y1601 E. Hazelton Ave. , Stockton, Calif. <br /> ' 'Telephone: (209). 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,� _,70 q W <br /> THIS -PERMIT EXPIRES I 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 t e .RTles and Re�u�.ations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION '�]�-911C,{,�.�,,_ - CENSUS TRACT <br /> ..s s f <br /> - – r rr//f2'E�/�J>' – — <br /> Owner's Name Phone <br /> Address l } City <br /> Contractor's Name �p� „pry, ��� License hone <br /> TYPE OF WORK (Check) : NEW WELL /y DEEPEN /_/ RECONDITION /7 DESTRUCTION 1-7" <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT 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 <br /> Irrigation Gravel Pack Depth of Grout Seal f <br /> Other Rotary Type of Grout e�� � --• <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor Fes _ <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ! / State Work Done <br /> PUMP UPAIR: / / State. Work Done <br /> .DFGTRUCTION OF WELL: Well Diameter �Guelf z,C 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 /> i <br /> SIGNED TITLE LlL� <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> DEPARTMENT USE ONLY CW <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PRASE OUT INSPECTION PHAU II FINAL INSPECTI5iN <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> s� <br /> tGOf <br /> CALL FOR A GROUT-INSPECTION PRIOR TO GROUTING .AND FINAL INS IO . <br /> E Hi 1426 - 5/731M <br />