Laserfiche WebLink
1;_� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF"06OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7�1__y sy4_'i <br /> THIS PERMIT EXPIRES I 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 District, <br /> JOB ADDRESS/LOCATION 01_&f Zl/S 4ee-i-I _ CENSUS TRACT <br /> Owner's Name` Al& Phone <br /> -1-ILE 3.I 3 <br /> Address > i� City Z 0 "// <br /> Contractor's Name � A4k,eAq License # Phonele/46 '-00574 <br /> �SIITJL�, rr� � f1�6--66 <br /> TYPE OF WORK (Check) ; NEW WELL _ DEEPEN /_/ RECONDITION /_/ DESTRUCTION /'7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK/Do SEWER LINES PIT PRIVY � <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS � <br /> Industrial Cable Tool Dia, of Well Excavation <br /> X Domestic/private - Drilled Dia. of Well Casing G <br /> Domestic/public Driven Gauge of Casing z, <br /> ;_z <br /> Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grouter <br /> Other Other Information ,, S <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump _ H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP UPAIR: / / State Work Done <br /> DFTRUCTION 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 'consiruction. 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 REPOR of the well and notify them before putting the wey,'12n use. The above <br /> information to the f my knowledge and belief. <br /> 7 <br /> SIGNED TIT <br /> (DRAW PLOT PLAN ON REVERSE S } <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I r� <br /> APPLICATION 'ACCEPTED BY DATE � 1 <br /> ADDITIONAL COMMENTS: t <br /> PHASE II GROUT INSPECT IO PHASE I /F AL I PECTION <br /> INSPECTION BY DATE 6 INSPECTION BY DATE . <br /> CALL FOR-A GROUT INSPECTION PRIOR-TO-G OUTING AND FINAL INSPECTION. <br /> -_E-H 1426 5/731M ' <br />