Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT . <br /> FOF..OkFICE USE: /1'601 E. Hazelton Ave. , Stockton, Calif. 7�/ 3 d C) <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ze-/3al <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued g rZg� <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 Sari Joaquin ` <br /> County Ordinance No. - 1862 andithe Rules and Regulations of the San Joaquin Local Health District. <br /> .TOB ADDRESS/LOCATION L4Z ew�lD[ CENSUS TRACT <br /> Owner's Name Phone <br /> 3 3 / !2-'7 <br /> Address 22 6 Z& City . <br /> Contractor's Name License #i? hone 7ffS � <br /> TYPE OF WORK (Check) : NEW WELL /Tf--'DEEPEN / / RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION / UMP REPAIR '/—/ PUMP REPLACEMENT /- <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES Q PIT PRIVY k <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER i <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Tn_dustrial, ! Cable Tool Dia. of Well Excavation <br /> tic/private , Drilled Dia. of Well .Casing <br /> Domestic/public yDriven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other A;:--P--Rotary Type of Grout . ,z- •w,�o <br /> Other Other Information <br /> y <br /> PUMP IPTALLATION: Contractor A IXA.Ae4d,) <br /> _ Type of Pump H.P. <br /> PUfIP` REPLACEMENT: ! 1 State Work Done <br /> PUMP UPAIR:�A / / State Work Done <br /> .DFIQTRUCTION OF WELL: Well Diameter g`p Approximate Depth !:?60 <br /> Describe Material and Procedure <br /> q <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 zwell "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 /> k <br /> A <br /> SIGNED946d TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I i <br /> APPLICATION ACCEPTED .BY DATE l- <br /> ADDITIONAL COMMENTS: 1U0 V <br /> PHASE II GROUT INSPECTION PHASE III/FI INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR JO/GROUTING AND FINAL INSPECTION. <br /> E H 1426 5/731M <br />