Laserfiche WebLink
OAV.7_d� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: ` (209)' 466-6781 <br /> APPLICATION FOR WELLICONSTRUCTION OR PUMP PERMIT Permit <br /> THIS `PERMIT 'EXPIRES 1 YEAR FROM DATE ISSUED Date Issued s z7 <br /> �j (Complete In Triplicate) 07t - &f-0-o <br /> Application ie hereby made to the °San ,.Ioaquin Local Health District for a permit to construct <br /> r 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 Regula ns of the San J qu Loc Health District. <br /> JOB ADDRESS/LOCATION /v7Z.- —77g1 2 CENSUS T CT <br /> Owner:'s- NaYmeZ�/ iC : / yam , / 1 � j' Phone'4 77 3-2<r6 <br /> Address f1 �� �l cJC'- �`-al�I City / a~T <br /> { Contractor's Name �U License # Phone " ! jll <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN / J RECONDITION /_7 DESTRUCTION /- <br /> PUMP INSTALLATIO PUMP REPAIR /% PUMP REPLACEMENT /_7 ° <br /> Other �<:� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER CL <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 /> Domestic/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 /> j Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> ! -PUMP-REPAIR: -. ,- . . , <br /> .,.__ / /' -'State-Work Done <br /> E <br /> „DESTRUCTION 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 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. <br /> SIGNED TITLE <br /> RAW PLOT PLAN ON REVERSE SIDE) <br /> _..__ FOR DEP USE ONLY - <br /> PHASE I <br /> ;:APPLICATION ACCEPTED etl, DATEl <br /> . ADDITIONAL COMMENTS: 4 -!ZA <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ATEA <br /> CALL FOR A GROUT INSPECTION.PRIOR TO .GROUTING AND FINAL INSPECTION. »� <br /> E H 1426 7/72 1M <br />