Laserfiche WebLink
' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> FOc. DICE USE: e: 209) 466-�6i81 <br /> Telephone: it No. .3- j;Yf } <br /> APPLICATION FOR WELL CONSTRUCTION ORPUMP PERMIT Perm �-- — � <br /> E ISSUED Date Issued 2-1 __,73 <br /> AR FROM DAT <br /> THIS <br /> /x- <br /> CHIS PERMIT EXPIRES 1 REAR FROM DAT7-3 t <br /> {Complete In Triplicate) permit to construct ; <br /> A lication is hereby made to the San Joaquin Locapplication is made inl Health District rcompliance with San Joaquin <br /> PP <br /> and/or install the work herein described. This pp <br /> Count Ordinance ,i3a.' 1862 and the Rules and Regulations of the San Joaquin acal health District. <br /> County � <br /> O SUS TRACT <br /> JOB ADDRESS/LOCATION b' <br /> . / U Phone <br /> Owner's Namea a✓r <br /> City , <br /> ' Address <br /> License # l 37Yr Phone ' <br /> Contractor's Nage <br /> TYPE OF WORK (Check): NEW WELL I! DEEP ! RECONDITION I I1 DESTRUCTIONCEME ! <br /> EN <br /> PUMP !INSTALLATION J / PUMP REPAIR.� PUMP REPLACEMENT L-7 � <br /> Other <br /> SEWER LINES PIT PRIVY <br /> -!� <br /> DISTANCE TO NEAREST: SEPTIC TANK CESSpOOL/SEEPAGE PIT OTHER <br /> f SEWAGE DISPOSAL FIELD <br /> ' ' <br /> .. ., •. •. . .:. . ..... . .. . _ CONSTRUCTION SPECIFICATIONS <br /> INTENDE7 USE TYPE OF 'WELL <br /> - -D'�a.'-of We11 E�cavatioxi <br /> Cable Tool <br /> i Iridiisfr al ` Dia ..of..we11 _Casing <br /> Dome:sttic/p <br /> rvate Drilled <br /> Driver► Gaue °f Grs�tg <br /> Domestic/public ou - Seal <br /> Gravel Pack Dep' h..o <br /> ' Irri gat�on --� e..of_-Grout - <br /> Other.._. . . .- .;- . ..Rotary.,... Typ <br /> Other Other Information <br /> PUMP INSTALLATION :Con ractor <br /> ....... .. 1' <br /> . TY�e. .o,f. Pump <br /> State <br /> )C/ Work Done <br /> PUMP REPLACEMENT" <br /> / 4e►r 1.9 f d'd <br /> J#. <br /> PUMP U_ PAIR. : .....- a Done_ <br /> St to Work D .. <br /> aeDph . <br /> Approxim t e t <br /> DF CTRUCTION� OF WELT: We1�l...Diaine ter <br /> ;Describe-Material and Procedure ., ... . <br /> : . <br /> I hexeb agree' tb 'coinpl'y' with all laws and regulations owelle'construction.Loc <br /> WithinHealth <br /> F'IFTEENDistrict <br /> DAYS <br /> Y <br /> and. the State:, of.;.California..per.taining`to..°r..regu3at�ng .. <br /> after completion of:my `.work cin a neva well, I will furnish the San Joaquin Local Health District <br /> WELL* D tILIERS' REl'ORx"'of :the Snell aril-motif, thein' bef ote .putting 'the well in use. The above <br /> rnfor�nation. iis...ttue;-to.;the .b.est .-af. m .-knob dge .an elief. <br /> t � LE .. . . <br /> SIGNED <br /> :. PL <br /> . : AN'..ON, <br /> a! R ... 5E' ,SIDE) . <br /> i <br /> 4 FOR DEPARTMENT USE ONLY <br /> ',! . . . ..:.. . .,.-. _.,..-.. , ....�. ..... ... . ... _ .. . ._ ._. ATE <br /> PH.AASSEEI . <br /> D r <br /> ypi' ICAT-ION...AGCEPTED :BY.. <br /> I ADDITIONAL COMMENTS': <br /> �. .. , .. _... . .. .:. ... ., •--- • -.. ... _.. : ' PHAS IJFI INSPECTION' <br /> :._...-. _ INSP-ECTION -BY :... <br /> DATE ' <br /> � <br /> INSPECTION...BYP�SE II GROi�T I.iVSPECi 4N;1"- .;-..... i, <br /> DATE..... .: _ <br /> 'CALL.Ft R.•A�-GRC2tJT TNSPEGTION�I''RIO'i..Tb,..GROUTING_AND_.FINAL_.INSPECTI <br /> /, 731rt <br />