Laserfiche WebLink
SAN JQAQUZNQUIN <br /> LOCAL HEALTH DISTRICT <br /> Qx. OFFICE EJSL: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> „ Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � _ � <br /> THIS PERMIT EMPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) ( 'E cC -USO�-2� <br /> Application is hereby madejto the San Joaquin Local Health District for a permit to consti-uct <br /> acid/or install the work 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 /> NI_ZfaS'-S ; i <br /> JOB ADDRESS/LOCATION !ACL. _ n "�A �}� <br /> �'t .e1, CENSUS TRAGI <br /> ` r it. Phone .- F <br /> Owner s Name <br /> Address - / ( .SiS City <br /> Contractor s Nametk <br /> �"T,icen �� PYiorie `Sze <br /> TYPE.OF WORK (Check) : NEW ,WELL le DEEPEN / / RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /- <br /> Other /J --- <br /> i <br /> i DISTANCE TO NEAREST: SEPTIC '1ANK SETTER LINES PIT PRIVY � <br /> XSEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE � TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> ✓ Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal r <br /> Other �- Rotary Type of Grout <br /> _ tL _c <br /> Other Other Information <br /> PUT INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> �zPU_.T REPLACEMENT: / / State Work Done <br /> PUMP 'tEPAIR: / / State Work Done <br /> .DFsTRUCTION 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 construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is tr e the stf m owl a and belief. <br /> t SIGNED l� TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR AEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL CO.filENTS: el- <br /> PHASE II GRO T INSPECIQN .�� rhea—�////f PF� NS ECTION <br /> INSPECTION BY DATE INSPECTION BY 6eVDATE <br /> t CALL FOR A GROUT INSPECTION-PRIOR TO GROUTING AND FINAL INSPE ION. <br /> E H 1426 K/7'11 <br />