Laserfiche WebLink
FOAQUIN LOCAL HEAL�TRICT . <br /> TOR OFFICE USE. 16 1 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (249) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. $?3 <br /> � f <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -l�• '] y <br /> ,� (Complete In Triplicate) <br /> Application' is hereby trade 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 Joaquir <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District, <br /> 4 _ <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Nameilii Vie/ G')--e Phone '51691 <br /> Address I4FO 47ty34 3` lit . tFGcA—I6-i�,t City s4clrrCH <br /> Contra tor's Name 'f7"T1. A10^4* ✓ yyy ('�+ Licen a Phone 0410•off yL <br /> Vey <br /> A <br /> TYPE OF WOR1G (Check) : NEW WELL / _(—.LEEPENRECONDITION,,/-7—. DESTRUCTION, /­7 <br /> PUMP INSTALLATION /_/ PUMP REPAIR PUMP <br /> / / REPLACEMENT /_7 v 1 <br /> DISTANCE TO'NEAREST: SEPTIC TANK 1 O SEWER LINES PIT PRIVY r.. <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT S i OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> X Industrial , Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing I_-- <br /> Irrigation Gia el Pack Depth of Grout Seal t <br /> Other Rotary Type of Grout A/c — c.Ay �' T <br /> OtherOther Information <br /> PUMP INSTALLATION: Contractor / �+ <br /> hOG• /{/pet'Ar, ILL-S O*"! <br /> TYPe of Pump .S'vr,+•'s.ibre "o $' t H.P. <br /> PUMP REPLACEMENT: / / State Work Donef <br /> PUMP REPAIR: ,State Work Done <br /> ESTRUCTION OF WELL: Well Diameter . <br /> - - �--• i r �- t F � � Appro ximate Depth <br /> Describe Materal-and Procedure { <br /> I hereby agree to comply with-alllaws—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- he-SanlJoaquin Local Health District a <br /> WELL DRILLERS REPORT of lthe well and notify them before putting the: welly in use. The above <br /> information is true to the best hof. my.,knowledge and belief,.—,j sckok d q <br /> SIGNED TITLE <br /> , <br /> 4 t (D PLOT PLAN ON REVERSE SIDE) <br /> F,. EPARTMENT USE ONLY <br /> PHASE I ; <br /> APPLICATION ACCEPTED BY - -F-� - DATE L <br /> ADDITIONAL COMMENTS: � .� <br /> 17 <br /> PHASE..II_.GROU 10 PHASE III./.F AL INSPEC ION <br /> INSPECTION BY A E INSPECTION DATE —r,-'7 <br /> CALL FOR A. GROUT INSP ION PRIOR TO GROUTING AND FINAL INSPECTION, <br /> E H 1426 7/72 IM <br />