Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFIC USE: 1601 E. Hazelton Ave. , Stockton, Calif. <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 G 1 <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 and the Rules and Regulations of the San Joaquin Local Health District. <br /> lqy <br /> JOB ADDRESS/LOCATION -N4 J3/�91 c�,� �.r.� �vrn�r D �1C.� CENSUS TRACT 2.p l_ o2,o -d3 <br /> Q t Yr a <br /> 'UJ"4-- -o <br /> Owner's Name /-� �Y ®cQ, /�u s Phone <br /> Address .j ES- 4 17 T j'�j_rd CD /fie City <br /> J <br /> Contractor's Name d ��� a. License # /�;,hone A-62-746 -6 <br /> i <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_� RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR />S/ PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES PIT PRIVY W <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <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 /> PUMP INSTALLATION: Contractor <br /> Type of Pump AI t H.P. / <br /> PUMP REPLACEMENT- State Work Done p/� rU•�-+ �r R n of Il J /f� f /� <br /> PUMP REPAIR: / / State Work Done <br /> .DESTRUCTION 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. The above <br /> information is true to the best of my knowled-ge--and belief. <br /> SIGNED — TIZALE p <br /> `-( W P PLAN ON ERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> ` APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> P II GROUT INSPECTION PHAS I FINAL INSPECTION <br /> INSPECTION BYcf DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M CC5 <br />