Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br />! FOL. OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. 9 <br /> Telephone:_ P (209) 466--6781 ��.� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7-�- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7--4-,7 <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. 1862 and the yyRules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION !�d• 7Z � /9-0- CENSUS TRACT <br /> Owner's Name p- � •--- T� Phone `j i7 31� ~ <br /> I <br /> Address City <br /> Contractors Name Li U�L1Ff C f License #.x65 4/ Phone (. <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN '/ / RECONDITION /_/l DESTRUCTION /- <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT / <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY , j i <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER ,J <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> W <br /> Industrial. - Cable Tool Dia. of Well Excavation g <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation <br /> Rotary eofGrout <br /> Pack Typhft Seal <br /> Other <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor lu-ra;vle"d ..cc-► �tc ,r ; <br /> n.C. <br /> Type of Pump • 6 n-t s:bie, H.P. 1 <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: j / State Work Done <br /> .DFRTRUCTION 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 /> fI <br /> SIGNED Ali iejV it �,p-x A_Lt y�`'fJ�t: ����U� TITLE q-f. <br /> /,---- -/QDRM4 PLAT PLAS ON REVERSE SIDE) T <br /> FOR DEPARTMENT USE ONLY <br /> PURSE I ' , :������ � 'f;?�✓ 'I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: _ <br /> PHASE II GROUT INSPECTION PHA INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> "CALL,-YOR---A•GROUT»-INSPECTION-PRIOR-TO.-GROUTING AND FINAL INSPECTION. . <br /> E -H 1426__. 5/731M <br />