Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOS.,OF1 ICI:. USI.• 1601 E. Hazelton Ave. , Stockton, Calif. <br /> - Telephone:. (209) 466-6783 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED -""—DW e ssue d �7� <br /> (Complete In Triplicate) <br /> al <br /> ealth <br /> t <br /> Application is hereby made to the San Joaqued. - Thisoapplication isDistrict <br /> made infor <br /> compliancetwithconstruct <br /> Joaq��.ii <br /> and/or install the wark herein described. PP .ricts <br /> County Ordinance No. 1862 axed the Rules and Regu ations of the San Joaquin Local:jn57�a16f'i��RN� <br /> , fEN TAR <br /> + ADDRESS/LOCATION E: �� FnpNT NCENSUS TRACT , <br /> JOB <br /> ! <br /> 4 . <br /> ,, Phone <br /> Owner's Name. N <br /> Address �- 1lUA R C R 0 city' Lv D T c. A I-,x=. <br /> ` Iq RM a � � <br /> ,(3 <br /> Contractor's Name License # ! 4 tr Phone <br /> { TYPE OF WORK {Cheek} : NEW WELL DEEPEN '/ / RECONDITION / / DESTRUCTION /rT <br /> PUMP INSTALLATION / /ks PUMP REPAIR N PUMP REPLACEMENT <br /> Other <br /> DISTANCE}TO'NEAREST: SEPTIC TAI <br /> t/' SEWER LINES PIT PRIVY <br /> OTHER <br /> SEWAGE DISPOSAL FIELD '.ESSPOOL/SEEPAGE PIT ` <br /> INTEI�AE - SE <br /> CONSTRUCTION SPECIFICATIONS <br /> TYPE OF WELL <br /> Industrial Cable Tool' Dia. of Well Excavation !!;�`• <br /> Domestic/private Drilled Dia. of Well Casing f0"' 1196 AG <br /> J <br /> ` <br /> Domestic/public s Driven Gauge of Casing o --/4" <br /> 4 <br /> Irrigation k Gravel Pack Depth of Grout Seal <br /> , <br /> Other ` Rotary Type of Grout i <br /> t Other Other Information . <br /> ' � xGf7Gj <br /> PUMP INSTALLATION: Contractor _ f -#, `c <br /> k Type. 5EPump <br /> r H.P. <br /> 5 ' S <br /> i 1%S1 <br /> PUMP REPLACEMENT: �!/ State, Work Done <br /> ,. PUHP-'tEP&K.— a. <br /> St ,Work Done <br /> - <br /> Approximate Depth <br /> DF-,TRU OF WELL: Well Diameter . <br /> T <br /> Describe Material and Procedure <br /> 1 with all laws and regulations of the San,kJoaquin Local Health District <br /> I hereby agree to comply <br /> It and the State of Cal.iforiiia pertaining to or regulating well construction. Within FIFTEEN SAY <br /> after completion of my wark on a new well.,. I will furnish the San Joaquin Local Health District <br /> ' WE DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. <br /> . 41 <br /> � } c TITLE <br /> ,i SIGNED ; <br /> RAW. PLO LAN.-ON REVERSE SIDE) <br /> 3 y <br /> FOR DEPARTMENT USE ONLY f <br /> F PHASE IDATE <br /> r APPLICATION ACCEPTED BY-f ' ` <br /> ADDITIONAL COMMENTS: E i PHASE III/FINAL INSPECTION <br /> PHASE II GR EC N INSPECTION BY DATE : 8 <br /> S.3 <br /> INSPECTI BY ATE a <br /> CALL F R GRO INSPEC ION PRIOR OU INC AND FINAL INSPECTION. <br />