Laserfiche WebLink
� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> rFOKROFFEICE USE: I� 1601 E. Hazelton Ave. , Stockton, Calif. <br /> I� Telephone: (209) 460--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7L*--- <br /> 6 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 412J— <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 nd the Rules and Regulations of the San Joaquin Local Health District. <br /> 31t. jZA14 W_ c+ff aox-4..' SX"l'-- <br /> 4 JOB ADDRESS/LOCATION ii 22 Qg=I SKa FF�: _ CENSUS TRACT <br /> Owner's Name fOL ta�, - - - Phone /, <br /> Address _ t�JEZ <br /> Ili. V%1 Al IQ IC�� �4 City &,74c 40&) �. <br /> II �- <br /> Contractor's Name �� D ~"License #�,� Q>� Phone <br /> TYPE OF WORK (Check) : .�j'1NEW WELL / / DEEPEN / / RECONDITION ./ / DESTRUCTION I—T <br /> •[PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT /? <br /> 11'Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER�LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> F INTENDED USEI` TYPE OF WELL . CONSTRUCTION SPECIFICATIONS <br /> Industrial I� Cable Tool: Dia. of Well Excavation <br /> Domestic/privates Drilled Dia, of Well-Casing .- 4 <br /> Domestic/public Driven , Gauge of Casing $0 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout T <br /> II Other Other Information <br /> PUMP-INSTALLATION: �Contractor +{, <br /> I Type of Pump H.P. <br /> -3 i' 13-7.3 — r©tv <br /> PUMP REPLACEMENT: / 5'/ State Work Done ���1rn(' °r ilk �r'F1�T <br /> ,. " ': ,. ""Srata-'Watk'Done <br /> PUMP`REPAIR°" ..-,, I' g - <br /> _DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> .1 Describe Material and Procedure <br /> I .3 <br /> II <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of Calif'orrii.a-pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my� wd.rk 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 /> ' fF� <br /> SIGNED <br /> TITLE` Y <br /> II (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: °'. <br /> PHASE II/'Z ROUT INSPECTION P III AL INSPECTION <br /> INSPECTION BY DATE INSPE ION B DATE S' <br /> + CALL FOR A GROU INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. 7J72 <br /> E H 1426 I <br />