Laserfiche WebLink
L 5� JOAQUIN LOCAL HEALTH DISTRICT"`' <br /> OR OFFICE USE: 160 Hazelton Ave. , Stockton, Ca r ; <br /> A Telephone : (209) 466-6781 � � e <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMf Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) -j <br /> implication is hereby made to the San. Joaquin Local Health District for a permit to construct <br /> z d/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 /> BSc F-- f-09-es023 -(30--c / <br /> B ADDRESS/LOCATION G`�l 2Si �C Q CENSUS TRACT <br /> QWner's Name Phone`7 p L 6 <br /> A. dress City <br /> C atractor's Name License I '1i1 Lk,4Phone7y-:'-("J <br /> T`PE OF WORK (Check) : NEW WELL / UEEPEN /J RECONDITION /_� DESTRUCTION /- <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / J <br /> E STANCE TO NEAREST: SEPTIC TANK -, SEWER LINES PIT PRIVY m <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �pp <br /> Industriala le Tool Dia, of Well Excavation (n <br /> Domestic/private Drilled Dia. of Well Casing _V) <br /> Dome tic/public _ _ Driven Gauge of Casing <br /> t/rrrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout (� <br /> _— Other Other Information m <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> P fP REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> C hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> r i the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> i. :er completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> TELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> Lr'ormation is true to the best of my knowledge and belief. <br /> iIGNED [� -{- o� �� TITLES'�"�Mnj }J <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> 'MASE I <br /> LPrLICATION ACCEPTED BY DATES �j/� (� � <br /> d +ITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE/III/FINAL INSPECTION <br /> INSPECTION BY DATE _ INSPECTION BY _r DATE ;,` ! }_ <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 I'M <br />