Laserfiche WebLink
zael SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE;. 1601 E. Hazelton Ave. , Stockton Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.17 6 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date.,.Issued � <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 compliaace, with San Joaqui <br /> County Ordinance No. 2862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION p <br /> CENSUS TRACT <br /> Owner's Name r Phone <br /> v� ~ 5:Z9 2-- <br /> Address $- kfCity <br /> Contractor's Name License # p Phone 7-ZQ <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION /-7 DESTRUCTION /_7 <br /> PUMPIINSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Ot er, — <br /> ' r c� , <br /> t DISTANCE TO NEAREST.:- ...SEPTIC T �,. _ w,. k . <br /> SEWER LINES �- - PIT-PRIVY <br /> r F S AGE DISPOSAL, F ELD CESSPOOL/SEEPAGE PIT OTHER <br /> .� - <br /> r <br /> INTENDED SE `` �TY �OFWE�LL � CONSTRUCTION SPECIFICATIONS <br /> Industrial' aleTool Dia, of Well Excavation <br /> k Domiestic/private Drilled Dia. of Well Casing <br /> Domestic/public - Driven Gauge of Casing <br /> Irrigation t Gravel Pack Depth of Grout Seal <br /> ' Other , <br /> 1 Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: . <br /> Contractor <br /> Contractor <br /> k Type of Pump H.P. , <br /> PUMP REPLACEMENT: F State Work_Donetr.... <br /> PUMP REPAIR, / / State Work Done <br /> ESTRUCTION 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 <br /> rict <br /> and the State -of California pertaining to or regulating well construction.LoWithin cal aFIFTEEN lth tDAYS <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. he above <br /> information is true to the bes of my knowledge and belief. <br /> SIGNED f <br /> TITLE <br /> W PLOTPL <br /> FOR AN ON REVE .RSE SIDE- <br /> DEPARTMENT USE-.ONLY <br /> PHASE -I <br /> APPLICATION ACCEPTED BY DATE /I> <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY i� DATE Z> a,-7.3 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. --- _� <br /> E H 1426 _ 7/72 1M)*-- <br /> r x _ 2!_. 0 " s #kF�fmi" 'r��Nt s la w 'a "w fsx�"�^i<aYfhl °?{mY )iia"l�°& S'F a tfiG ��?W.'aa v, t: r arM•., ,a -. , ..... .,. <br />