Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> For-OFFICE USE: 1601 E. Hazelfuft- .ve. , Stockton, Calif. <br /> iM Telephone: (209) 466-6781 <br /> Ip APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 3-�( <br /> IM <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE'ISSUED Date Issued _LL14_-�3 <br /> (Complete In Triplicate) <br /> Application is hereby- made. to the San Joaquin Local Health District for a permit to construct <br /> and/or iistall ��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 _ °'� 7 >s S -T-0'c-,Lm-; e ' CENSUS TRACT <br /> Owner's Name Phone <br /> Address 4 d City . . g04 e. z <br /> Contractor's Name License # WI-J Phone r <br /> TYPE OF WORK (Check) : NEW WELL /7 DEEPEN '/—/ RECONDITION /_/ DESTRUCTION /-/_7AL <br /> PUMP INSTLATION / / PUREPAIR /�/ PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LI=NES _ 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-/pr.ivate. : Drilled Dia:` of Well.-Casing <br /> _ Domestic/`public Driven Gauge of Casing <br /> Irrigation ' Gravel Pack Depth of Groot Seal <br /> Other Rotary Type of Grout <br /> iK Other Other Information <br /> I� <br /> PUMP INSTALLATION: Contractor 4 <br /> Type of Pump ac. H.P. <br /> PUMP REPLACE MENT« J / State Work Done <br /> PUMP ','EPAIR: / /. State Work Done A­y'1�- Ql <br /> ;DRgTRUCTION 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 R ,PORT. 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. t <br /> SIGNED TLE ..1� { <br /> PLOT PLAN O4RE SESIDE) <br /> AOR DEPARTMENT USE ONLY <br /> PHASE I , <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL CO1 , <br /> -'-F- <br /> NTS: {' <br /> PHASE OUT INSPECTION <br /> PH&SE I/)aINAL INSPECTIO <br /> INSPECTION BY I� DATE . INSPECTION BY OPATE t <br /> ,CALL-FOR A.GROUT INSPECTION PRIOR TO. GROUTING'AND FINAL INSP ON. <br /> E H 1426 j.._._._. - q/73im <br />