Laserfiche WebLink
SAN JOAQUIN LOCAL QMLTH DISTRICT <br /> FOFrOFFsE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> i Telephone: x(209)"4,66j81 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) _ <br /> Application is t:ereby 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 Joaqui <br /> County Ordinance No. 1.862 Ad the R e and Regulations o he San Joaquin Local Health District. <br /> I <br /> I JOB ADDRESS/LOCATION (o �o <br /> CENSUS TRACT <br /> Owner's Name Y t h S <br /> Phone -V <br /> Address <br /> Cit�4 <br /> Y <br /> Contrac'tor's Name + , <br /> L cense 2 7-')?hone 0,16d <br /> �* it .; <br /> TYPE OF WORK (Chack): NEW WELL /DEEPEN -/ RECONDITION /7 DESTRUCTION /� <br /> sq <br /> PiTMP.i INSTALLATION y PUMP REPAIR /—/ PUMP REPLACEMENT .: f 'IN <br /> Other / <br /> '1I ; <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY € { <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PfT - <br /> PROPERTY LINE .. PRIVATE DOI�STIC WELL ' PUBLIC ,DOMESTIC WML <br /> INTENDED USE TYPE OF WELL ICONSI".RUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> —7 Domestic/private z Drilled � Dia. of Well Casing <br /> Domestic/public i . Driven t + Gauge .of.,ell C 4 <br /> Irrigation i - F:� �� H i <br /> Gravel Pack--1 _. <br /> thof Griout Se <br /> hProtection , i Rotary a of Gr . <br /> —Disposal ~T Other r Other InfoIrmat on <br /> Geophysical <br /> Surface Seal. In)stalled B : <br /> PUMP INSTALLATION: ' <br /> ContraFctor1�, <br /> Type .of Pump ��- ` � t t H.P. <br /> PUMA' REPLACEMENT: i <br /> State Work Done ; . <br /> PUMP '.REPAIR• k Done <br /> / / State Wor „ ` . . . . . <br /> DESTRUCTION OF WELL: Well-Diameter ,' - <br /> Describe Material and Procedure = Approximate Depth <br /> I hereby agree to complyiwithiall. laws and regulations of the San eoaquin Local Health District <br /> And the State Cal rnia Pe' rtaining to or regulating well '-const coon. Within FIFTEEN DAYS <br /> after compl ion of my work 4on a new.0ell -'Irwil1\furnish the San 1.O'aquin Local Health District <br /> WELL DRIL S REPORT —� -« r - �` '�� trio a <br /> the'>well and not thein'before putting.. the..well. in use,... The above <br /> informat n is rue the es ledge <br /> PRIOR TO GROU A - lief. I.,WILL CALL 5 A GROUT INSPECTION. <br /> k <br /> TITLEI <br /> (DRAW PLOT .PLAN ON REVERSE SI i R. <br /> PHASE I <br /> t FORD PARTMENT USE ONLY <br /> AP�PLICATION ACCEPTED BY. <br /> ADDITIONAL COMMENTS ' - -- DATE - - 79= <br /> I GROUT INSPECTION '~" b <br /> INSPECTION BY DATE p Y �+INAL^INSPECTION C <br /> -� `� INSPECTION BY <br /> DATE -'l <br /> E H 1426 Rev. 1.--74 <br />