Laserfiche WebLink
�v SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209)` 466-6781 <br /> t APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT:,, Permit No. <br /> s "4 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued,&7 <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. 1862And the Rul and Regulations of` the Sar: Joaquin Local Health District. , <br /> JOB ADDRESS/ CA N ,0. CENSUS TRACT <br /> Owner's Name Phone <br /> Address y :). City _ <br /> Contractor's NameZA QZAu4 �-- ��. License 4��S�a/OPhone --� . <br /> r <br /> f` TYPE OF WORK (Check): NEW WELL /Z7-�EEPEN /_/ RECONDITION /_7 DESTRUCTION /_7 <br /> AL <br /> f PUMP INSTLATION /PUMP REPAIR / / PUMP REPLACEMENT /_ <br /> Other / / 4 <br /> f DISTANCE TO NEAREST: SEPTIC TANK [�f] -SEWER LIVES pct PIT PRIVY <br /> SEWAGE DISP SAL FIELD/ <br /> QCESSPOOL/SEEPAGE PIT --- OTHER <br /> i INTENDED USE, TYPE OF HELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> ___4,.e43vffiestic/private f Drilled Dia, of Well Casing �► <br /> Domestic/public, f '—Driven Gauge of Casing - 42— <br /> Irrigation Gravel Pack_ Depth of Grout Se <br /> Other `Mary, Type of Grout �►� -r <br /> Other Other Information <br /> PUMP INSTALLATION., Contractor <br /> Type of Pump H.P. <br /> e- <br /> P PUMP REPLACEMENT: / / State Work-Done <br /> PUMP REPAIR: /% State Work DoneY " <br /> ESTRUCTION OF WELL: Well Diameter -_ Approximate Depth <br /> F <br /> Describe Material -and Procedure 'y,:• <br /> I hereby agree to comply with all laws and regulations-of-the San--Joaquin Local Health District, <br /> 4 and the State -of California pertaining to or regulating well.Fconstruction. Within FIFTEEN DAYS,. ,, <br /> after completion of my work on a new well, I will furnish the San Joaquin LocaltHealth 'Distriet-a <br /> WELL DRILLERS REPORT of the well and notify them before p`uttin' -thei'tiell 'in use" The above <br /> info tion is true to the bes o knowledge. and belief. RT " : <br /> SIGNED f`' ; w ,. f <br /> TITLE . �i �Ll9�/ �. '. <br /> ADRAW PLOT - . ON�cREVERSE SIDE- --,, - <br /> FOR DEPARTMENT USE ONLY <br /> PHASE . u / 11 <br /> APPLICATION ACCEPTED BY _W�w DATE/ i <br />' ADDITIONAL COMMENTS: <br /> r <br /> PHASE II GROUT I4SPECTION _ "' PHASE III F AL INSPECTION <br /> INSPECTION BY DATE $- !� INSPECTION BY DATE ZZ12, 7,S� <br /> CALL FOR A CRO4 INSPECTION PRIOR TO GROUTiNG AND FINAL INSPECTION. <br /> � <br /> E H 1426 �., . ,, ^r- `. L. k �; ; a , 7/72 1M <br />