Laserfiche WebLink
SAN JOAQUIN LOCAL ITC,ALTH DISTRICT. <br /> FOR OFFICE USE: 1601 E. Hazelton Ave.•,, Stockton, Calif. <br /> Telephone: . (20 ) 466-6781' - <br /> APPLICATION <br /> 66--6781 .APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. _ 2.q, n <br /> THIS PERMIT EXPIRES I. YEAR FROM DATE-ISSUED, <br /> 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.eIS62 and the. Rules and Re ulations of the San'Joaquin Local Health District. <br /> v <br /> JOB ADDRESS/LOCATION �R �. / -� CENSUS TRACT <br /> Owner's Name AC <br /> �/OV-Z ' <br /> .�� Phone <br /> Address <br /> .City <br /> Contractors Name License 4 Phone5fy �dA3 <br /> TYPE OF WORK (Check) : NEW WELL/�EPEN f RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION/ UMP REPAIR /_/ PUMP REPLACEMENT /_7 <br /> Other /% <br /> DISTANCE-TO-'NEAREST: SEPTIC TANK ;r „SEWER LINES PIT PRIVY F <br /> SEWAGE DISPOSAL FIELD !1� CESSPOOL/SEEPAGE PIT OTHER G" <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 0 <br /> mestic/private Drilled Dia. of Well Casing S e <br /> Domestic/public Driven f i <br /> Gauge of Casing <br /> Irrigation '`� _��Sravel Pack Depth of Grout Seal € <br /> Other _,4--Rotary Type of Grout .} <br /> Other ��e'� <br /> Other Information , <br /> wv <br /> PUMP INSTALLATION.: , Contractor /V <br /> iType of Pum JIIIIH.P. <br /> _ _ <br /> PUMP REPLACEMENT: `/ ./ S tate -Work-Done �'� <br /> PUMP REPAIR: `; StateWork DonI ' r <br />\ •ELL <br />.))ESTRUCTION .OR- W <br /> We11 Diameter, Approximate Depth r 1 <br /> Describe Material a rpce e i, w t <br /> I hereby agree to comply with all laws •a wregu a ion_s_ of the, S n J.oaquin'L©¢al Health:4District-- <br /> and the State of California pertaining to or regulating well construction. 'V`ittiiri�.;FT17TEEN DAYS.. <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health nistrict,-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 of my knowledge and belief. <br /> SIGNED TITLE d ou A! F—' 1&- <br /> r <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED DATE 'Z 0 Ly <br /> ADDITIONAL COMMENTS• - :. -- <br /> P OUT INSPECTION PHA.S NAL� PECTION _ <br /> INSPECTION B DATE Z�' INSPECTIOWBY CALL FOR P CTIONPRIOR TO GROUTING AND FINAL <br /> E H 1426 - ; - Y _ - 4 72 <br />