Laserfiche WebLink
z - <br /> / '1 JOAQUIN LOCAL HEALTH DISTRIC" �- <br /> POR OFFICE USE: 160--� . Hazelton Ave. , Stockton, Calri. (� / <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 7S=/ice <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued7-�5- <br /> (Complete In Triplicate) <br /> .Dvlication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> id/or install the work herein described. This application is made in compliance with San Joaquin <br /> ,snty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JB ADDRESS/LOCATION J 12, J D,� ��j u;ct / Z CENSUS TRACT <br /> ,mer's Name _f--.SLr 6 � lYc' /�,-�-c1 11V11- lle Phone LJ 7 <br /> .dress Z J��� Ali k'c.-a l a L/,L Gi✓ � � %�l�c'i7 K ti City <br /> Dntractor's Name � f` License Phone <br /> ,; y Z 3 �yij <br /> IPE OF WORK (Check) : NEW WELL / T DEEPEN /_/ RECONDITION /_/ DESTRUCTION <br /> PUMP INSTALLATION /i-f PUMP REPAIR / / PUMP REPLACEMENT 1-7 y <br /> Other <br /> ISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY U1 <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER O <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <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 /> LtiiP INSTALLATION: Contractor <br /> Type of Pump '' H.P. J <br /> UMP REPLACEMENT: / / State Work Done <br /> LTMSP REPAIR: / / State Work Done <br /> I;STRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> ,nd the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> fter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> JELL DRILLERS REPORT of the well and notify them before putting the well in use. The ab e <br /> _nformation is true to the best of my knowledge and belief. <br /> IGNED TITLE U <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> 'RASE I u <br /> 1PPLICATION ACCEPTED BY DATE <br /> \DDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAJIVWFINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE a 5' <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPE ON. 7/72 1M <br /> E H 1426 <br />