Laserfiche WebLink
cd tl� <br /> SAN JOAQUIN LOCAL4 HEALTH DISTL%__ ... <br /> 'FOE�ZFFICE USE: i 1601 E. Hazelton Ave: , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.' 3 11 <br /> 73~ �p6 ' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ? -73 , <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 shade in compliance with Sart Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local. Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT ' <br /> Owner's Name L0_UiA R basin _ _ Phone <br /> Address 1312 W,.Oak St City Iodi <br /> ,Contractor's frame Domestic Service <br /> j License41-1-4455-Phone 368-4004 <br /> TYPE OF WORK (Check) : NEW WELL / 7 DEEPEN '/ / RECONDITION ,/ <br /> _/ / DESTRUCTION7, <br /> PUMP INSTALLATION /:W_PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK 70 SEWER LINES 75 PIT PRIVY � <br /> SEWAGE DISPOSAL FIELD 75CESSPOOL/SEEPAGE PIT; - OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ' <br /> Industrial x Cable Tool Dia. of Well Excavation 1214t <br /> X Domestic/private Drilled Dia. of Well Casing - 8 <br /> Domestic/public Driven Gauge of Casing 12Ga <br /> Irrigation Gravel Pack Depth of Grout Seal . <br /> _ Other Rotary Type of Grout S�Ltd4 cement r <br /> Other Other Information t <br /> F <br /> PUTT INSTALLATION: Contractor Domestic Service <br /> Type of Pump Submersible --- H.P. _3H,P S' <br /> a <br /> PUMP REPLACEMENT: / / State Work Done <br /> n <br /> 4 PUMP 'tEPAIR: / / State Work Done <br /> k { <br />'t 1FRTRU6TION OF WELL: Well Diameter Approximate Depth i <br /> Describe Material and Procedure �, € <br /># 4 <br /> 1 hereby agree to comply with all laws and regulations of the San Joaquin Local Heal-th 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 Heal-th District a <br /> ij WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is ue to the best of my knowledge and belief. <br /> SIGNED TITLE OwHler <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> t APPLICATION ACCEPTED .BY &,, _ <br /> DATE _2- 73'! <br /> ADDITIONAL COMMENTS: <br /> - - " PHAS II GROUT INSPECTION _..PHASE"III/FINAL INSPECTION <br /> ' INSPECTION BY� DATE - 7 3 4, . INSPECTION BY DATE E 2-/�:� <br /> r CALL-FOR A .GROUT: INSPECTION.-PRIOR TO GROUTING AND FINAL INSPECTION. <br />?; ; E H :1426a 5/731M <br />