Laserfiche WebLink
r y <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT e , <br /> FOF..OFKGam' USE: J1601 E. Hazelton Ave. , Stockton, Calif. <br /> V_ Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 —l�p1�41 <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 compliance with San Joaquin' <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health Disprict. <br /> F130 <br /> JOB ADDRESS/LOCATION �, CENSUS TRACT ; <br /> Owner's Name ��7�•�l°°°" -PPhhone _ Z <br /> 0 , <br /> Address .. City <br /> Contractor's Name " <br /> License #ag() Phone - <br /> TYPE OF WORK (Check) ., NEW WELLDEEPEN '/—/_ <br /> C ) � RECONDITION / / DESTRUCTION J`7 <br /> PUMP INSTALLATION /GJ PUMP REPAIR /_/ PUMP REPLACEMENT /7 <br /> Other ,/ / <br /> It <br /> DISTANCE TO NEAREST: SEPTICITAlVK Q SEWER LINES PIT PRIVY <br /> X SEWAGEi�DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS C3 <br /> Industrial fl Cable Tool Dia. of Well Excavation <br /> Domestic/private ii Drilled Dia. of Well Casing ' <br /> Domestic/public �1 Driven Gauge of Casing _ <br /> Irrigation fI Gravel Pack Depth of Grout Seal . _ <br /> Other ,I Rotary Type of Grout �� <br /> Other Other Information is&h —A/ ,o <br /> P <br /> PUMP INSTALLATION; Contractor r !� LG� Kdd C <br /> Type ot f Pump e.r►, .�• H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP UPAIR: / / State Work Done <br /> �r r <br /> ,DFqTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe.,Material and Procedureff��7 <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"constructi.on. 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 Giell and notify them before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. <br /> EDA JAt 14 a TITLE . <br /> (DRA LOT PLAN ON REV E SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCZPT _D -8Y , DATE -) .12t/ <br /> ADDITIONAL C0MMEN I :� sr/ .' <br /> PEASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY _DATE .� ).� <br /> . CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. �^ <br /> E H 1426 t�/71 iu <br />