Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOr.:OFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. L y 3 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -� -�� <br /> r (Complete In Triplicate.) � <br /> Application- i.s hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the,Mork herein described. , This application is made in compliance with San Joaqui <br /> County Ordinance- No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> (T3 {'V1.a r <br /> JOB ADDRESS/LOCATION OLD 'HWY 50 rHRTSMAN RT)_ � Q. �5...��. - CENSUS TRACT <br /> Owner's Dame RANDY Phone 835-2002 <br /> Address 2 ST_ _ City " " TRACY <br /> License # Phone ' <br /> Contractor's Name ,NN3'NC�, R O DRIT, SING CO.,I�jC. ,�„1 b�22 -5643 <br /> TYPE OF WORK (Check) : NEW WELL fK/ DEEPEN/ / RECONDITION Cl DESTRUCTION 1-7 <br /> PUMP INSTALLATION / / PUMP REPAIR '/ I PUMP REPLACEMENT /_7 <br /> Other /. / — <br /> DISTANCE TO NEAREST: SEPTIC TANK J10 SEWER LINES 1jr', PIT PRIVY 1nj,4 <br /> C SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> ` u <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation prr <br /> W,W> Domestic/private Drilled Dia, of Well Casing str <br /> X Domestic/public Driven Gauge of Casing _12 Gk <br /> Irrigation Gravel Pack Depth of Grout Seal 501 <br /> Other X__— Rotary Type of Grout _BENTONITE <br /> a Other Other Information <br /> SLAB- BY OWNER <br /> I <br /> + PUMP INSTALLATION: Contractor tN w { 'L. 8 <br /> Type of Pump 2"V2 w• eq, s 001c,c, H.P. L <br /> a PUMP REPLA.CFMENT: / /� State Work Bone _:2 /'/:} <br /> ' PUMP`- EPAIR: ` /`I° "State.Work Done �` <br /> DF,-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material ander ocedure - <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 'construction. Within FIFTEEN DA <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District7l <br /> WELL 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 /> i SIGNED . 45ZTITLE <br /> {� .rte --- -- <br /> DRAW PLOT PLAN ON REVERSE SIDE) <br /> ` FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED .BY CDATE <br /> ' ADDITIONAL COMMENTS: _ U <br /> PHASE II GROUT INSPECTION PHASE II/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE -23 <br /> �.. CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INS ION. <br /> E H 1426 .5/731M <br />