Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOI. OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif.. �- <br /> Telephone: (209) 466--6781 7�( -� P <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 4 W <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued G//_7C <br /> (Complete In Triplicate) <br /> Application is hereby -jade 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 Sant Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> i <br /> JOB ADDRESS/LOCATION `���/ . � �ah�.. / �- 'C_ CENSUS TRACT <br /> Owner's Name / _ f Phone /-,24-0Y7 <br /> Address City c_ .27tF - <br /> Contractor's Name License #..2Ge1ZF Phone .5���Cl� <br /> i <br /> TYPE OF WORK (Check) : NEW WELL /DEEPEN / / RECONDITION /_/ DESTRUCTION /`"]" <br /> PUMP INSTAI:LATION 0, 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' j <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial �,Z 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 <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: ContractorC - ` ?f <br /> - -- Type of Pump e.,4s" ;' + H.P. a�a <br /> r <br /> PUMP REPLACEMENT: /_7 State Work Done <br /> PUMP UPAIR: / / State Work Done <br /> .DFSTRUCTION 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 m �ork on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REP of the well and notify them before putting the well in use. The above <br /> information rue to the best of my knowledge and belief. <br /> i <br /> SIGNED TITLE £,sa <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> i FOR DEPARTMENT USE ONLY <br /> E PHASE I <br /> APPLICATION ACCEPTED Y �. ,-Ci - -— DATE 4 I <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE IIIbFIN`a INSPECTION <br /> INSPECTION' BY E INSPECTION BY DATE</7 <br /> "....CALLFOK---A-GRO T- NSPECTT PRIOR .TO GROUTING AND FINAL INSPECTION. <br /> .T If ter- K/7A 1 <br />