Laserfiche WebLink
. OFF ! JOAQUIN LOCAL HEALTH DISTRICTf-) <br /> FOR OFFICE USE: 6/ 16� Hazelton Ave, , Stockton, Cay <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, 1x:73 <br /> (Complete In Triplicate) p <br /> Application is hereby made to the San Joaquin Local Health Distri � ED <br /> construct <br /> and/or install the work herein described. This application is made in compliance with San Joaqui <br /> County Ordinance No.. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION .!�� fC� ` / -=zt.F.G'" �,�� -�'r- 1. CENSUS TRACT Sil7 <br /> Owner's Namej A, '� -_-- <br /> Phone <br /> Address lJ` c <br /> Citya _� <br /> Contractor's Name '. License # c <br /> Phone " <br /> TYPE OF WORK (Check): NEW WELL /% DEEPEN/_7 RECONDITION /_7 DESTRUCTION /77 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT;1' /7 <br /> Other /% — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE ,DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER els <br /> INTE DED USE TYPE OF WE CONSTRUCTION SPECIFICATION d <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor ,.>:A.:, .• .,,, �._ <. '�3Y E �'�:�:; <br /> Type of Pump H P. <br /> ' �._ <br /> PUMP REPLACEMENT: . State Work Don ' E <br /> h <br /> 'i-C <br /> PUMP REPAIR: / / State Work Done - <br /> ESTRUCTION OF WELL: Well Diameter 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.;l The above <br /> information is to the best of my knowledge and belief, ! <br /> f <br /> SIGNED { p TITLEs.G��(� <br /> RAW PLOT PLAN ON REVERSE SIDE <br /> • FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> r PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> I INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION: i <br /> E H 1426 1i 7/72 1M W,— <br />