Laserfiche WebLink
71� <br /> _ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF.OIf,ua USE: 1601 E. Hazelton Ave. , Stockton, Calif. ^t <br /> Telephone: (209) 466--6781 r✓ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES l 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 Sart Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION A,'&SA e-sq-W e5 1-6 17-L-)e fl4Ge CENSUS TRACT <br /> Owner's Name I /z::7 a b° / ! d Phone <br /> J <br /> Address 1 S �G t Y� 222 PJ City <br /> Contractor's Name LJ k-n License # Phone q6 Z <br /> TYPE OF WORK (Check) : NEW WELL <br /> / DEEPEN/ / RECONDITION / DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT _. ?" <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TAINK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> A Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/publicDriven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal \ <br /> Other Rotary Type of Grout O <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. ' <br /> PUMP REPLACEMENT: State Work Done -!!S- <br /> PUMP `ZEPAIR: / / State Work Done <br /> PF'-TRUCTION 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 complet' y work an a n ell, I will furnish the San Joaquin Local Health District a . <br /> WELL DRILL S REPORT of .the well nd notAf tem before putting the well in use. The above <br /> nformati n is true o ,the best m ge and belief. <br /> SIGNED . TITLE, <br /> (DMW PLOT PLAN ON REVERSE SIDE) <br /> .; DEPARTMENT USE ONLY <br /> PHASE I � <br /> APPLICATION ACCEPTED BY r DATE `r�/�:714 <br /> ADDITIONAL' COMMENTS: q '� <br /> PHASE II T IN EC . ON P SET /F INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUP' INSPECTION PRIOR TO GROUTING AND FINAL INSP ION. <br /> �/7 3 IM <br />