Laserfiche WebLink
` SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF.,OFFIIWX, USL: 1601 E. Hazelton Ave. , Stockton, Calif. r' c ,r <br /> Telephone: (.209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �/37� <br /> (Complete In Triplicate) <br /> Application is hereby made tot the San Joaquin Local Health District for a permit to construct ;€ <br />- -an,dior install the work herein described. ' This application is made in compliance with Sari Joaquin <br /> Conty Ordinance No. 1862 and', the Rules and Regulations of the Sari Joaquin Local. Health District. <br /> JOB ADDRESSILOCATIONd �! cENsiTs TRACT <br /> Owner's Name 9e �_ r�' _V3 Z_ <br /> Address City <br /> Contractq` s Name _ Al. �►� ' - f'i=r sN License � e <br /> TYPE OF WORK (Check) . NEW +TELLC DEEPEN '/ / RECONDITION / / DESTRUCTION /-7 � <br /> v' PUMP INSTALLATION 14 ru'MP REPAIR / / PUMP REPLACEMENT; /? <br /> Other <br /> DISTA,YCE TO NEAREST: SEPTIC TANK!&* r,r SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial __LG<able Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing lult k. f <br /> �mestic/public 1 Driven Gauge of Casing <br /> rigation I Gravel Pack Depth of Grout Seal y <br /> Other J Rotary Type of Grout <br /> „ Other , ; +� Other Information <br /> PUMP INSTALLATION: Contractor L j ,v 3,+ <br /> Type of 'Pump -tat V H.P. <br /> PUMP REPLACEMENT: f%€ State Work-66neA' s _ { <br /> PUMP 'tEPAIR. <br /> / / State Work Done s ; <br /> .DF'gTRUCTION OF WELL: Well Diameter E 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 true to the best of my knowledge and belief. ` <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) �. r <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED .BY3 -Z—?g <br /> DATE <br /> ADDITIONAL COMMENTS: <br /> PRASE 11 GR TT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY .- DATE INSPECTION BY DATE <br /> CALL FOR A GROUT IN ECTION PRIOR TO GROUTING AND FINAL INSPECT N. <br /> E H 1426 _ K /.7-Ai <br />