Laserfiche WebLink
SAN JOAQUIN LOCAL UEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209):<.46666781 <br /> APPLICATION FOR WELL CONSTRUCTION."OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES_.I' YEAR- FROM- DATE ISSUED'- , . :Date' Issued <br /> (Complete 'It•.Trip1: c:ate) ii V i; <br /> Applicat'i•on!4s•:,�aerebyf.madei..to 1-the-;•Szn:7 oaquin::Local Health District!for-ra,.permit to construct <br /> and/or install the work herein described. in <br /> -icatibn!i's�made= incompliance .with San•Joaquin <br /> County,0rdinance«No:;,Ql862r;:and:i.th&Rules; and,Regulations,aof',the, San.-.Joaquin Local Health District. <br /> .a�C,1.:�?'r,'L� ..T<-.jf Jfl .fi 7C .� iV'�'. T v � if..`.1 Ps F'. t - .t.. .f; ,,' .:. ; •: <br /> L <br /> JOB ADDRESS/LOCATION - p,e /�' _ �-. r,�' •• _. t CENSUS -TRACT <br /> .J:.`•'E'�i.�J:� 'y-£ .i(a� ''S7 4 j 6 a;= t � _� t.! tai..'. g�}' e t� i- �_t L, I r-f .°sk k: . - . �,... -. t :.i. ' • <br /> Owner:r. Namee_�V_ � i' a('5:1 — ! t 5 3 Y 1 � � 'l k(/� ?•c I.f: ,u� Phone' f <br /> Address ""r ZeEff•i/' City <br /> Contractor's Namer <br /> - /f' . License # <br /> _ <br /> .�.91 Phone.: �a <br /> TYPE OF WORK (Check): NEW WELL-'/-7 DEEPEN -/_7 RECONDITION DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR Itj PUMP REPLACEMENT /-7 <br /> Other <br /> { <br /> DISTANCE TO NEAREST: SEPTIC TANK, SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> 1 UNTENDED 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 /> &Z.Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> 3 <br /> PUMP INSTALLATION: Contractor r..�a,o 0,/W <br /> Type of Pump , r H.P. r <br /> PUMP REPLACEMENT:' / / State Work Done <br /> PUMP REPAIR: /% State Work Done <br /> .DESTRUCTION OF WELL: Well Diameter Approximate Depth s <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> andithe 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 /> WELD. DRILLERRS REPORT of the well and notify them before putting the well in use. The above <br /> inf6rmation.i's true to the best of my knowledge and belief. <br /> 000, <br /> SIGNED �f �f �o � TITLE <br /> ,(DRAW PLOT PLAN ON REVERSE SIDE <br /> /� FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE IT ROUT �TNSTPECTTION PRASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY / -- DATE .3-8-9,3 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 142b 4/72 IM'" <br /> L_._ <br />