Laserfiche WebLink
n�© ._ V,/ 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 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Z <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 p� U FR�` d y k TCENSUS TRACT <br /> Owner's Name c�lAll 1-�a F M Phone <br /> Address °D .5'0 k�D "R 1'Ck _ City _ R), P61V- <br /> Contractor's Name - 3:a h u �. o License 11 ZZq2qVPhone 8'3.f ?3"7 0 <br /> TYPE OF WORK (Check) : NEW WELL '/�/ DEEPEN '/ / RECONDITION /_ DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <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 X Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing /ry 'It-_1!1 'L�- <br /> Domestic/public Driven Gauge of Casing Zy a Z:6 <br /> Irrigation Gravel .Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done A i [7t)i�3Ti�3 <br /> PUMP REPAIR: / / State Work Done <br /> ,DESTRUCTION 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 OWL 2 9 A ij TITLE _ QI&L,” <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR_ZEMTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED B U DATE 7i <br /> ADDITIONAL COMMENTS: M <br /> PHASE II GROUT INSPECTION P II / I '� INSPECTION <br /> INSPECTION BY DATE INSPECTION�Y 7 ' / lDATE -�`�_- <br /> CALL VOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> .E H 1426 4/72 1M <br />