Laserfiche WebLink
` 61d SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FCR-. FFICE USE:. 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7L-- /'� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 5 if-7G <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 Joaquil <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District: <br /> UWS ,5,v �t L`WA,$- P.,aro ZXXVTf' a�F CENSUS TRACT <br /> JOB ADDRESS/LOCATION 14A <br /> j Phone <br /> Owner's Name. e A.Jl <br /> *Address <br /> LI A) 2 D City /��►�m_PD <br /> Sen ,�aaquin Pumip CO.. License # Phone 3G -��/7 <br /> Contractor's Name i• <br /> BVI, �u <br /> L,,a C¢'ri4n.r q 95240 <br /> TYPE OF WORK (Check) : NEW WELL /_/ DEEPEN RECONDITION %� DESTRUCTION /?,�/ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT �' <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> P <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> F Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of W411 Casing <br /> I• Domestic/public Driven Gauge of Casing <br /> Irrigation_ ......-....._---- ----- - Gravel.-PackDep th--of_-Grout Seal <br /> G Other Rotary Type of Groui' iA <br /> Other Other Information 1 <br /> PUMP INSTALLATIONS <br /> Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / {' State Work Done /ee l&ce g L'/3Lye <br /> PUMP _REPAIR: .. �._ .-./ _/_ =State Work.-Done_�_ - <br /> + J)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 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 <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 /> Sari JoGquin rump Ca. <br /> SIGNED C TITLE -- -' <br /> k I (DRAW PLOT PLAN ON REVERSE SIDE <br /> l FOR DEPARTMENT USE ONLY Loci-, Calli alnia 95240 <br /> PHASE I t � <br /> APPLICATION ACCEPTED BY ! DATE <br /> ADDITIONAL COMMENTS: - /90 <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTI N <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> 7/72 1M <br /> E H 1426 <br />