Laserfiche WebLink
SAN 3OAQUIN LOCAL HEALTH DISTRICT { <br /> -- 1.601 E. Hazelton Ave. , Stockton, Calif' { <br /> [,,i1)F.' OFFICE USE: Telephone: (209) 466-6783 <br /> APPLICATION POR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �Date Issued �L 7� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSt3ED � <br /> + (Complete In Triplicate) permitrict for a to construct <br /> Application is hereby made to the San Joaquin Locallication i,sHealth tmade irk compliance with San Joaquin <br /> and/or install the work herein described, ' This app <br /> �3eh pisCrict. <br /> County Ordinance No, 1862 and the Rules and. Regulations of the San Joaquin Local jtea <br /> • _,, i , r� CENSUS TRACT <br /> JOB ADDRESS/LOCATION / <br /> U20 <br /> Phone <br /> Owner`s Name <br /> - city . . <br /> Address T6,61 <br /> License �Fhon <br /> Contractor's Dame - - - <br /> WORK (Check): NEW WELL � DEEPEN / / � RECONDITION !^P�E�PLACEMENT— 1_7 <br /> TION <br /> TYPE OF ( pump INSTALLATION jg/-PUMP REPAIR / / <br /> Other 1 / <br /> SEWER LINE _ PIT PRIVY <br /> 4 DISTANCE TO NEAREST: SEPTIC T/UgK /D- CE55 OP LO /SEEPAGE PIT OTHER <br /> SEWAGE DISPOSAL FIELD 6\ <br /> A <br /> CONSTRUCTION SPECIFICATIONS \ <br /> INTENDED USE TYPE OF WELL \ <br /> ation <br /> Industrial _ Carle Tool Dia. of Well Excav �- <br /> Drilled Dia. of Well Casing <br /> Domestic/private Drivers. Gauge of Casing <br /> Domestic/public Depth of Grout Seal <br /> Irrigation �_ Gravel Pack p <br /> g } vRotary Type of Grout <br /> Other `�"" Other Other Information <br /> j� +/ a(�✓/✓�%fz� 4-/` d C� ,e �f.1� �" GCss,5d-�..C�✓� .. <br /> PUMP INSTALLATION:,X-Contradtor <br /> Type of Pump <br /> State Work Done <br /> PUMA' REPLACEMENT: I! <br /> DF�TRUCTION OF WELL: Wall Diameter <br /> Approximate Depth <br /> z Describe Material and Procedure <br /> i T 'hereby agree to comply <br /> with all laws and regulations of the San Joaquin Local Hearth District <br /> and the State of CAYS <br /> alifornia pertaining to or regulating we3.1`'constructuin+LocalhHealth Distin FIFTEEN Dict i <br /> after completion of my work on a new well, I will furnish the San Joaquin <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 /> TITLE <br /> SIGNED ' (DRAW PLOT PLAN ON REVERSE SI <br /> FOR DEPARTMENT USE ONLY <br /> �_y_ �. <br /> PHASE I -) [%(// \ DATE <br /> APPLICATION ACCEPTED BY <br /> `� ADDITIONAL COMMENTS: ! P IT/FI L INSPECTION <br /> PHASE IT GROUT NSPECTION�! / INSPECTION B DATE 1r� <br /> INSPECTION BY ATE �� C7 <br /> CALL FOR A GROUT INSPEC ON PRIOR TO GROUTING AND FINAL INSPE ION. r,/3 <br />