Laserfiche WebLink
! ; <br /> "'- r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> R"OFFICE USE: V 601 E. Hazelton Ave. , Stockton, Calif. ; <br /> Telephone: (209) 466-6781 `II <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.�3 1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued/ j <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 San Joaquin <br /> County Ordinance .No. 1862 and the Rules and Regulations of the San Joaquin Local Health District, 1 <br /> JOB ADDRESS/LOCATION wJ `� W. � D T I1 �`7 cr •-- CENSUS TRACT <br /> Owner's Name1 0 Phone CIx^ ly4 <br /> Address (.c1 , L,-A City L.AT/1 ?01� <br /> Contractor's Name y License #.1227M Phone <br /> 5 <br /> TYPE OF WORK (Check) : NEW WELL/ J DEEPEN RECONDITION /_/ DESTRUCTION /? <br /> F PUMP INSTLATION / / PIMP REPAIR <br /> / / PUMP PLACEMENT /� <br /> AL <br /> Other -4 <br /> _���� a �s�` Y u u <br /> DISTANCE TO NEAREST SEPTIC TAIN7". SEWER LINES 4 O_ PIT PRIVY pp-- <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> ;INT/ D USE v TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> ,`Industrial :, _3 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 rj.f Rotary Type of Grout <br /> I Other Other Information <br /> �T <br /> PU�g' INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / 'State Work Done ' <br /> T { <br /> PUMP UPAIR: / / State Work Done <br /> ,DFcTRUCTION 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 i <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-arid belief. _. <br /> h SIGNED TITLE <br />!, - - - (DRAW -PLOT PLAN ON REVERSE SIDE) <br /> f FOR DEPARTMENT USE ONLY <br /> C PHASE I �, <br />!, APPLICATION ACCEPTED .BY I �` Gig( DATE <br /> ADDITIONAL COMI-MNTS: <br />` <br /> PHASE -11--GROUT—INSPECTION PHASE II_ FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY . E O <br /> CALL FOR A-GROUT INSPECTION.-PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 5/731M <br />