Laserfiche WebLink
SAN JOAQUIN LOCAL.1-1EALTH DISTRICT <br /> FOR OFFICE USE (` 1601 E. Hazelton Ave. , Stockton, Calif. <br /> i Telephone: (209) 466-6781 <br /> i APPLICATION FOR WELL CONSTRUCTION-OR PUMP PERMIT Permit No:'�✓'�ll✓O' <br /> THIS PERMIT EXPIRES I- YEAR FROM DATE ISSUED Date Issued <br /> e '! (Complete In Triplicate) <br /> , Application is hereby'•made„ta _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 jNo. 1862 ab'd the Rules- and Regulations, of the San Joaquin Local Health District. <br /> 191 .2==, ' <br /> JOB ADDRESS/LOCAT .�. ;. .... Z� /3� <br /> I -ss - <br /> ON` �'A d �NSUS: TRACT <br /> Owner's:'Name � r r f� yr . 'c ..:.. Phone <br /> Address _.� ”. ��. City(Rf ee A/A -ec-A <br /> Contractor's Name License irk 3Phone . 2-:_-623 <br /> IV <br /> TYPE OF WORK ,(Check)-:", NEW WELL •DEEPEN '/ ./ ' 'RECONDITION/�* DE8TRUCTION <br /> PUMP.'IINSTALLATION /PUMP REPAIR/ / PUMP REPLACEMENT /? <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK.. L4:�j SEWER-.LI ES � a y- PIT PRIVY + <br /> SEWAGE DISPOSAL FIELD v.� .`CESSPOOL/SEEPAGE,'PI .. OTHER <br /> INTENDED USE ., TYPE OF WELL '° % E. CONSTRUCTION',SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well •Exeavation !!� <br /> mestic/private 4 Drilled Dia. of Well Casing <br /> ` Domestic/public !: Driven Gauge of Casing <br /> Irrigation „ Gravel Pack Depth of Grout Seal MQ &Z r, <br /> Other i Mary Type, of Grout v-: ti r-r F <br /> =r Other Other Information(- �^,.(� . SQA 6 /* <br /> PUMP INSTALLATION: Contractor -.• � <br /> Type] of Pump H.P. I� <br /> PUMP REPLACEMENT: / / ii State Work Done <br /> PUMP.-RE? -9 „-�/�7/.1-State„Work�_Done <br /> ,DESTRUCTION OF WELL: Well! Diameter` - C(Approximate Depth' ' <br /> Describe Material and Procedure ` <br /> I hereby agree to comply with all laws and regulations-of_theaSan-Joaquin_Local Real•th-District <br /> and the State of California' pertaining to or regulating well construction. Within FIFTEEN•DAYS <br /> after completion of my work! on a new well, I will furnish the Sari.�'Joaqu'in Local Health^District a <br /> WELL DRILLERS REPORT of the,' well and notify them before putting the we1LI i.n use. 'The Labove <br /> informat' ' s true to best ofn nowled'ge and belief. J '° 14 <br /> � <br /> SIGNED -r <br /> � 1 TITLE <br /> u (DRAW PLOT PLAN ON REU,ERSE SIDE) c <br /> FOR DEPARTMENT USE.ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: 1E> <br /> :PHASE 11 GROUT INSPECTION PHAVIVWAL INSPECTION <br /> INSPECTION BY r�_./(],T .M DATE 3- 7 INSPECTION Y DATE ' �;- <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> i E H 1426 1M <br />