Laserfiche WebLink
r ,r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 -E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--67$1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -7z,-16 l � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE• ISSUED Date Issued I)" <br /> ' (Complete In Triplicate) <br /> Application is here made to ;the San Joaquin Local Health District for a permit to construct <br /> k and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance,No-. 1862--and -the Rules and Regulations of/ the San Joaquin Local Health District. <br /> £ JOB ADDRESS/LOCATION. ?"/JCS S . �+q Jr �Glf �1,�-� : -- CENSUS -TRACT <br /> Owner.'s Name i v�,r s �t� `, �� r a..�. Phone ' <br /> H <br /> Address. City <br /> Contractor's Name _. CSG License #l Phone-S��C/� , <br /> TYPE OFWORK (Check) : NEW WELL L7 DEEPEN /_7 RECONDITION /� DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR '/ / PUMP REPLACEMENT /7 <br /> Other 1 I <br /> DISTANCE TO NEAREST: SEPTIC TANK 2-1V `7` SEWER LINES , PIT PRIVY` <br /> SEWAGE DISPOSAL FIELD 2Z) CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 41 <br /> Industrial Cable Tool Dia, of Well Excavation: AIW '2 <br /> Domestic/private Drilled Dia. f Well Casing <br /> Domestic/public Driven Gaug of Casing C <br /> ! Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type f Grout <br /> Other - Other\information ' `` l <br /> PUMP INSTALLATION: Contractor <br /> H.P. / <br /> a Type of Pump - . <br /> 'PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: �tate .Work Done <br /> F i <br /> ,DESTRUCTION OF WELL: Well Diameter '-Approximate Depth <br /> Describe Material-and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local -'Health District <br /> and the State of California pertaining to or regulating well constr.uctioii.x `Within FIFTEEN DAYS <br /> after comp-letion.,-of my work—on a new�relZ;"I will furn`isiz the"Sani, oaqu n Isocal 'Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting ilie well_in-ease_. The above <br /> information is true to the,,:best of my knowledge and belief. <br /> SIGNED`9• �� 9YJP/��' TITL <br /> 1 / (DRAW PLOT PLAN ON REVERSE SIDE _ <br /> -- FOR DEPARTMENT USE ONLY <br /> .PHASE I <br /> APPLICATION ACCEPTED BY DATE Bc <br /> ! ADDITIONAL COMMENTS: <br /> L�_- <br /> PHAS5 II GROUT INSPEC IO PHASE4,;IFINAL INSPECTION <br /> INSPECTION BY t DATE INSPECTION BY DATE <br /> CALL FOR GRO INSPECTION PRIOR TO GROUTING AND FINAL INSPECTI <br /> a 4/72 1M <br /> E H 1426 ' <br />