Laserfiche WebLink
-S SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE.- 1601 E. Hazelton,",Ave.- 'Stockton, Calif. ` <br /> Telephone:s:_ (209),,A66",6781 <br /> APPLICATION FOR WELL CONSTRUCTION:'-,OR PUMP PERMIT Permit No. ��- <br /> THIS PERMIT iEXPIRES;1=YEAR FROM!:DAT.EstSSUEDh <br /> (completetl-Tr•ip1uat6) ' .T <br /> Applicat�anbianhbreby-{madexto the;sSan; Joaquin.:Local Health' District for`>a�permit�'to `construct <br /> and/or install the work herein described. Thi:s.�hp�licatlonn ig1-,made jin';compliancef-4itfi' Sari Joaquin <br /> County':>Qrrlinaiice(:No c;1862�:.`:andtha 1e t egulatiya a Safi:1 s and =R ns ofttr juin Local::Health Distrfct. <br /> Jn.�y �' .s - = t ' <br /> _ � q � ..(',}-R^i (_1-syr: :5 <br /> 3 .f/i/� [s F i :. <br /> JOB ADDRESS/LOCATION i r>CENSUS°TRACT"r <br /> ti Yr t' ` `f.r` E7'I.,t .�3 T ratV { � ) 1- _ <br /> •t- .r 1 - f._2 i i•; <br /> dwner!e.iyNam C#.i- j, <br /> !,Addr <br /> 4ess <br /> w �i <br /> Za <br /> Contractor shame -�- License # Phone .� =' ' <br /> TYPE OF WORKF(Check): XEW_W. ELL' I / DEEPEN :/__7 RECONDITION /�-/�DESTRUCTION�/-7 <br /> �r PUMP INSTALLATION ,/ / PUMP REPAIR /7 PUMP REPLACEMENT <br /> 4ter l .l f <br /> DISTANCE TO NEAREST:: - SEPTIC TANK-'. SEWER LINES PTT PRIVY <br /> SEWAGEDISPOSAL FIELD , CESSPOOL/SEEPAGE PIT ... OTHER <br /> V - <br /> INTENDED USE TYPE OF WELL;. CONSTRUCTION:SPECIFICATIONS <br /> Industrial.. ._ Cable' .Tool Dia., o.f. 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 Rotary Type of Grout <br /> Other Other: Information <br /> t �---- <br /> PUMP INSTALLATION: ` Contractor <br /> 1 <br /> ' Type of Puwl H.P.:' <br /> PUMP REPLACEMENT: <br /> . /�/ State Work Done - <br /> I <br /> PUMP REPAIR: / / State Work Done i <br /> i <br /> .DESTRUCTION OF WELL: . =.Weil .Diameter <br /> h <br /> Describe Material, and Procedure' a p <br /> pproxim to De .t J- <br /> : Describe <br /> 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 Distridi a <br /> WELL DRILLERS' REPORT. of the well and.notify them before.putting .the well in. use.. ..The ,above <br /> information true to: the best ;of 'my knowledge and belief. , <br /> OT PLAN ON REVERSESID t <br /> SIGNED {{ <br /> TITLE " I <br /> (DRAW PL E <br /> FOR DEPARTMENT USE ONLY '. <br /> PHASE I <br /> APPLICATION ACCEPTED BY L , <br /> DATE �. <br /> ADDITIONAL COMMEiM _i7 <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE i <br /> ,. <br /> GALL FOR A GROUT. INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> _. .... .._ .. . ._... .�_._.. .,.�...___.._. <br /> 4/72 .. <br />