Laserfiche WebLink
SAN jOAQUIN LOCAL HEALTH DISTzRICT <br /> f <br /> FOR OFFICE USE: 1601 E. Hazelton Ave;, Stockton, Calif. <br /> a Telephone: {204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION. OR PUMP PERMITPermit No. <br /> THIS.-:PERMIT. EXPIRES 1 YEAR FROM DATE -ISSUED bate. Issued -3 <br /> (Complete In Triplicate) <br /> Application is hereby*made ti 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 /> JOB ADDRESS/LOCATION ZLO PjA DA CENSUS TRACT <br /> Owners Name t' . z/ Phone <br /> r - <br /> Address • 7._L-L f , 1.�6'' A 12,4 Cit �G <br /> Contractor's Name via C G,..-.._ License # Phone "yGz���� <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION /_/ DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br />' Other ./ / <br /> DISTANCE TO NEAREST: SEPTIC.ITANK SEWER LINES PIT PRIVY <br /> t SEWAGEIDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OP WELL CONSTRUCTION SPECIFICATIONS j ^ <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private .' Drilled Dia, of Well Casing QT <br /> Domestic/public- f Driven Gauge of Casing ' <br /> Irrigation, , - Gravel Pack Depth of Grout Seal ,R <br /> Other _ - r_ _ Rotary Type f Grout �'�f� r <br /> 0 <br /> T ' Other - - � Other Information <br /> E <br /> PUMP INSTALLATION'., Contractor <br /> Type .of Pump a H.P. <br /> PUMP REPLACEMENT: .° / '/ -State Work Done <br /> PUMP REPAIR: r�+ / / State 'Work Done <br /> ,DESTRUCTION OF WELL: Weil Diameter<"" Approxima a Depth <br /> c <br /> Describ,e Material and-Procedure <br /> I hereby agree to comply-with all-laws and regulations of the San Joaquin Local Health District j <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, li will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS'.REPORT o-f- the well and notify them before putting the well in use. The above <br /> information-,is truet6vrhe best of m knowledge and'hel3ef <br /> _ s <br /> SIGNED TITLE '. -. <br /> DRAW PLOT PLAN ON REVERSE SIDE) <br /> tF R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYMA DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II G NSP ON A _ *', -; +:, PHASE Ii /FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION B DAT N <br /> / 73 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSP CTION. <br /> E h 1426 4/72 1M ` <br /> 4 F <br />