Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOL',Oi-j�,ICE USL: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued - o2S=7S� <br /> I (Complete In Triplicate) <br /> application is hereby made tolthe- 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 Sart Joaquin <br /> County Ordinance No. 1862 an,d' the Rules and Regulations of the San Joaquin Local Health District, <br /> JOB ADDRESSILOCATION CENSUS TRACT <br /> Owner's Name ECS ` f� IG ETA _ Phone I <br /> // <br /> Address 1/710 / 001t <br /> S.E. City <br /> Contractor's Name License #,2(,5 76/ Phone <br /> TYPE OF WORK (Check) : NEW,WELL / / DEEPEN '/ / RECONDITION %/ DESTRUCTION /_7 <br /> PUMP INSTALLATION ,_�,W PLW REPAIR I I PUMP REPLACEMENT /_7 <br /> Other l/ / <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES PIT PRIVY <br /> SE14AGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial I � Cable Tool Dia. of Well Excavation <br /> Domestic./private 1 Drilled Dia. of Well Casing <br /> Domestic/public 1 Driven Gauge of Casing <br /> Irrigation t Gravel Pack Depth of Grout Seal <br /> Other I Rotary Type of Grout <br /> I Other Other Information <br /> PUMP INSTALLATION: Contractor _ (111 VrP /� �U P/I(J <br /> lType 'of Pump AIE H•P' - 0 <br /> _ a <br /> PUMP REPLACEMENT I I State Work Done <br /> PUMP-'tEPAIR: j / State Work Done <br /> DApproximate FsTRUCTION OF WELL: We11�Diameter PP 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 /> 3 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 <br /> knowledge a b lief. / <br /> SIGNED UV �C S LES19�S,S' F 4E/1'7//!lam <br /> (D W�P T PLAN ON REVERSE SIDE} <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASF&ZItjQROUT INSPECTION P /FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE �'5-.�5 <br />}' CALL FOR A G U .ZNSPECJQSWt TQ GROUTING AND F1 AL JNSPC p, l <br />