Laserfiche WebLink
` SAN JOAQUIN LOCAL HEALTH DISTRICT ` <br /> FOF.:OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.,_3_ <br /> THIS PERMIT. EXPIRES 1 XEAR�.FROM DATE ISSUED Date Issued j0-,2�-j� <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 trork 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,: I! �t� i t (C �//{ % �' CENSUS TRACT <br /> Owner's Name .. A9 �L c� GSL g Phone <br /> Address / 7 f lC'` !dt - City �19 c. <br /> Contractor's Name ZZ& ` Xy /I License llz � �- Phone <br /> TYPE OF WORK (Check) : NEW WELL Y/ DEEPEN/ / RECONDITION /7 DESTRUCTION /7 � . <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK Z�t2. SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PTT 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 /> omestic/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 H.P. . <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP '7EPAIR: / / State Work Done <br /> .DF.,ZTRUCTION 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 <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 knowledge and belief. <br /> SIGNS TITLE W 17ez�ly <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR.DEPARTMENT USE ONLY <br /> PHASE I <br /> E APPLICATION ACCEPTED BY DATE /a <br />' ADDITIONAL COMMENTS: <br /> PHA T I SPECTION PH4SE I INAL NSPEC'TION <br /> k INSPECTION BY DATE //�.1TT INSPECTION B ATE <br /> CALL FOR A -I ECTION PRIOR TO GROUTTNG :AND FINAL INSPECTION. . <br /> E H 1426 <br /> 5/731X (:3 ; <br />