Laserfiche WebLink
FOR OFFICE USE: 1601 E. Hazelton' Ave. , Stockton, Calif. <br /> Telephone: (209). 466-6781 7�`�9® <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 3- 36(1. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date"Issued 1.17 ' <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: 1.862 and the pRules and Regulations :.bf the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION OQ E. �t�� �a� �T, ` Jib c- Z-�:1.� CENSUS TRACT �.�� -L <br /> Owner°s Name ] (.) F.� M 1`� t Co �*' Phone �(-z_.(�c" <br /> Address � e- .. . .. . ... . <br /> Za City <br /> Contractor's Name s. �i_ i I A 'License # Phone4/77-/,FS-j. <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN' / / RECONDITION /_/ DESTRUCTION /? <br /> AL <br /> PUMP INSTLATION PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST. SEPTIC TANK SEWER LINES Com' + PTT 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 / 0 1 Ai tA. <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public , Driven Gauge of Casing d 00 <br /> Irrigation Gravel Pack Depth'of Grout Seal _ . <br /> Other j/ Rotary Type of Grout. <br /> Other Other Information (� <br /> PUMP INSTALLATION:' . Contractor -^ _CLA-a r <br /> ..Type of a X3 <br /> Pu ia <br /> 1 1" 3 -- - <br /> PUMP REPLACEMENT: / / State Work Done' <br /> PUMP REPAIR: /-7 State, Work Don-e' <br /> ,DESTRUCTION 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 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 /> SIGNED TITLE IV,- ' - <br /> (DRAW PLOT PLAN ON REVERSE SIDE— <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHA INSPECTION PHASE N SPECTION <br /> 'INSPECTION BY ATE � . INSPECTION BYE` ATE 7 <br /> CAL FOR A G NS CTYON PRIOR-TO GROUTING AND FINAL INSPECTION. <br /> 7/72 1111 <br />