Laserfiche WebLink
4 a <br /> SAN JOAQUIN LOCAL/ <br /> HEALTH DISTRICT �1r`a0 <br /> -� <br /> FOE.OFFICE USE: fi 1.601 E. Hazelton Ave. , Stockton, Calif. 606, <br /> l <br /> k � I�, <br /> Telephoner (209) 466-6781 " v <br />' APPLICATION FOR WELL CONSTRUCTION-OR PUMP PERMIT Permit No. <br /> THIS PERMIT -EXPIRES 1 YEAR FROM DATE ISSUED Date Issued _7,3'� ' <br /> n <br /> (Complete In Triplicate) <br /> ' <br /> Application is hereby de to the San Joaquin Local Health District for a permit to construct <br /> and/or install the wor4herein 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 /> ' CENSUS TRACT <br /> JOB ADDRESS/LOCATION <br /> : a <br /> I� <br /> `Owner's Name �� 'CI�J^�? .DN (>N _ Phone _ 1 <br /> city _ p <br /> ,( Address --- r <br /> ` Contractor's Name 1 License #,1V"Phone <br /> } LEW <br /> .TYPEOFWORK (Check) : _ �WELL-/DEEPEN (-J RECONDITION / /.; ,DESTRUCTION / - <br /> UMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /? , <br /> ' . ,Other / J <br /> DISTANCE TO NEAREST: SEPTIC TANK EWER LINES PIT PRIVY <br /> r SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER 1 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS t <br /> Industrial Cable Tool Dia. of Well Excavation ; <br /> i2Domestic/private Drilled Dia. of Well Casing <br /> - - - Domestic/public Driven Gauge of Casing ):7— <br /> Irrigation <br /> 2Irrigation I Gravel Pack Depth of Grout Seal Q <br /> Other Rotary Type of Grout 54 1 <br /> �G Other Other Information <br /> PUMP INSTALLATION: <br /> �Contractor <br /> Type of Pump Zzb e-k CL H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP TtEPAIR: / / State Work Done <br /> ;DF-,TRUCTION OF WELL: ;Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> } I <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 mywork 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 /> t information is true to the best of my knowledge and belief. <br /> SIGNED TITLE <br /> RAW PLOT PLAN ON REVERSE SIDE) <br /> + FO DEPARTMENT USE ONLY <br /> PHASE I � <br /> APPLICATION ACCEPTED .BY DATE <br /> ADDITIONAL COMMENTS: II <br /> PHASE II R S T PHASE III/FINAL INSPECTION <br /> INSPECTION BYi DATE INSPECTION BY DATE f/ <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> 5/731M_E H 1426 II �'+ <br /> k <br />