Laserfiche WebLink
i <br /> ]y/ S JOAQUiN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. , Stockton, P: <br /> FOF. OFFICE US1's: Telephone; (209) 466-6781 <br /> i <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> �--'-" AP i <br /> Date Issued <br /> THISPERMITEXPIRES 1 YEAR FROM DATE 'ISSUED <br /> (Complete In Triplicate) permit to construct <br /> This application is made in compliance wit�hSOistri ari Joaquin , <br /> Application is hereby made to the San Joaquin Local Health District fO7` a p a� deal <br /> pP <br /> and/or install the work herein descry i <br /> County Ordinance No. 1862 and the Rules and Regulatiana of the 'San Joaqu n o 'li <br /> I CENSUS TRACT41 <br /> J r <br /> JOBADDRESS/LOCATION 0o0 . <br /> Phone <br /> I owner's Name <br /> Address S Phoneu_ t'ry <br /> License <br /> Contractor's Name <br /> RECONDITION I / DESTRUCTION IT <br /> TYPE OF WORK (Check): NEW WELL / DEEPEN / / PUMP REPLACEMENT <br /> PM ,INSTA LATION f 1 PUMP REPAIR/ .1 <br /> . Other#-i / <br /> LINES _ TZ-3 PRIVY <br /> SEWER <br /> DISTANCE TO NEAREST: SEPTIC TANTY, CESSPOOL/SEEPAGE PIT OTHER _ <br /> SELVAGE DISPOSAL FIELD — <br /> CONSTRUCTION SPECIFICATIONS <br /> TYPE OF WELL <br /> INT�aNDED USE Cable Tool: Dia. of Well Excavation <br /> Industrial Drilled Dia. of Well Casing �' <br /> G� <br /> Domestic/private t Driven Gauge of Casing <br /> Domestic/Public Mme_ Depth of Grout Seal <br /> a Gravel Pack P <br /> Irrigations'—"' Rotor Type of Grout <br /> Other othery,_____._ Other Information <br /> 1 Pump INSTALLATION: Contractor - H.P. <br /> Type of Pump <br /> _f <br /> PUMP REPLACEMENT: I / 1 State Work Done <br /> -State Work Done . <br /> Approximate Depth <br /> DFRTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> lth <br /> rict <br /> I hereby agree to comply with all laws and regulations °WeZlthe <br /> 'construction.Local <br /> Within aFIFTEEN tDAYS <br /> and the State of California pertaining to or regulating <br /> after completion of my <br /> work on a new well, I will ,furnish the San Joaquin Local Health-. District <br /> above tract <br /> WELL DRILLERS REPORT of the well and notify them beefand beli tting the well in use. The a�iove <br /> information is true to the bes of my knowledge <br /> TITLE <br /> SIGNED {DRAW pLOT pLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> DATE <br /> PIJASE I <br /> APPLICATION ACCEPTEDmBY INS M <br /> ADDITIONAL COD ENTS: PHASE III/FINAL DATES IO 7"" ' - <br /> PHASE II G Ol3T. INSPECTION INSPECTION BY <br /> INSPECTION BY DATE <br /> ! CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> F u 1426 <br />