Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601. E. Hazelton0AVe.',: -Stockton, Calif. <br /> Telephone.:' -(209) :46b-6781 <br /> APPLICATION FOR WELL• CONSTRUCTION_ OR PUMP PERMIT Permit No.7 �Q <br /> THIS PERMIT,EXRIRES; I-YEAR' ItOrf T�t�TE ISSUED Date ssued s � <br /> (tomAete 'In Triplicate) <br /> Application.-isahereby:made"r to :the SanIJoaquin'Local Health District for..,a permit" 'to construct <br /> ' and/or install the. work herein described. This,app- ication.is.made'.in;compliance with San Joaquin <br /> County,Ordiriance ,No: ;,1862.and;,.th6.-Rules'-Ia%id`-Regulations'-of the San Joaquin Local, Health District. <br /> 2.70--0_3. <br /> JOB ADDRESS/LOCATION .25-00 f 7, 410?r1l G f !/�// I�1� CENSUS TRACT <br /> owner! z,Name _,Phone tdj/(„G-'" .$D*/ s . <br /> Address ..� . �'. . ''I/l/ l - ---. City 701 <br /> SW <br /> i <br /> Contractor's Name (� License # Phone ' ?—S <br /> TYPE OF WORK (Check) : ' NEW WELT/vI DEEPEN I J RECONDITION I_�I DESTRUCTION I? <br /> ; PUMP INSTALLATION / UMP REPAIR / I PUMP REPLACEMENT <br /> Other, f / <br /> DISTANCE'TO NEAREST: 'SEPTIC TANK SEWER LINESPIT PRIVY <br /> f 'SEWAGE DISPOSAL. FIELD CESSPOOL/SEEPAGE PIT OTHER ` <br /> ' NTENDED USE ! TYPE 0F_ WELL CONSTRUCTION SPECIFICATIONS <br /> industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing /li'sr <br /> Domestic/public !' Driven` Gauge of Casing Lie�'" . }n <br /> Irrigation ; Gravel. Pack Depth of Grout Seal AW <br /> ' Other Rotary Type of Grout �0 ►(7if' <br /> Other Other Information t <br /> PUMP INSTALLATION: Contractor e G, . <br /> Type of Pump a/I,Q'/ .• , H.P. <br /> _ - V <br /> PUMP REPLACEMENT: / / State Work Done ,. <br /> PUMP REPAIR: / / State Work Done <br /> .DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure . <br /> 3 <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-knowledge and belief. j <br /> -„" <br /> TITLE ry , <br /> SIGNED ) <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE a <br /> ADDITIONAL COMMENTS.- <br /> PHASE <br /> OMMENTS:PHASE II GROUT INSPECTION PHA II/FIN .CTION <br /> INSPECTION BY DATE INSPECTION BY E <br /> . CALL ,FOR A GROUT INSPECTION,.PRIOR-'TO GROUTING AND FINAL INSPECTION. <br /> E H...1426 4/72 1M <br />