Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT 4k <br /> 70—.'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <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 <br /> (Complete In Triplicate) _ <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> 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 m , .� / a T: Lyljy Coe. Z ff, J 1]iii &.ZAXNSUS TRACT <br /> Owner's Name j` x] M y.4)ZZ �o ✓ <br /> $ �Fs77B8 <br /> ' Address / <br /> � __.17...��1 .. dlZg�y IV 4.4 j f�Q11,0 City 6ffG <br /> Contractor's Name- l�i� �d.►rJ T License # a 29,o Io Phone ,50 <br /> 4-7 <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN !_l RECONDITION / / DESTRUCTION /—T <br /> PUMP INSTALLATION f! PbW REPAIR / / PUMP REPLACEMENT <br /> r Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT "OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation (A <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing C <br /> Irrigation _ Gr va e' 'Pack 'Depth of Grout "Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> j - <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump u� ----- - - - H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP "2EPA�R� A - <br /> / /—State Work Donex <br /> DFr-TRUCTION OF WELL: Well Diameter t Approximate Depth <br /> Describe Material and Procedure _ <br /> s <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 /> F, <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 �J <br /> 4, <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 3CL <br /> ADDITIONAL CO:SMENTS: <br /> PHASE II GROUT INSPECTION PHASE <br /> III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A. GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECT ON. <br /> --_E H 1426 - 5/731M <br />