Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT _ <br /> FOR OFFICE USE:r1601 E. Hazeltori-'Ave.,, Stockton, Calif. <br /> Telephone,:,.a;. <br /> (209).,:,466-6781- <br /> 1111 P ICATION FOR WELL CONSTRUCTIONVOR PUNT PERMIT Permit No. <br /> -7 <br /> THIS PERMIT,-E-XPI-RES!.�lc-"Y{EAR.iF-ROMDA�T-E-TISSUED "T,'Date, Is*su-e'd lf(� <br /> (Oiompliatei :in,T_r-ipal,�&te) <br /> Applicat,i•o'rr').,i"s,�.h'areby.i: -de_(,to rthe ,Sanf Jcoaquin`:-Lolcal .11&,al:th Disttic,t'_' flor' a�pezmit to,c-onstruct <br /> and/or install the work herein described. Th-is.;-,aV'pl(ication,, is�ma-dp_`, in; compliance. with. San"'Joaquii <br /> County.j,Ordinavce),-No�iq -862-!7zn-dl,,-th&-,,Runleri)and'�'-Regula'tk..otis-,,of�:,.'the "Sati.;Joaquin.,L-ocal"HiBalth District. <br /> 4 <br /> V "M &W &)1' <br /> JOB ADDRESS/LOCATION 1 A&Zr' !:.- CENSUS:.TRACT,:. <br /> Cho le- <br /> t <br /> to Owner!.sdF <br /> tj q rk; r. Phone'­ <br /> AddressS//4 - <br /> 'City <br /> Contractor's Nam 4 i.1 License #Qyj?o8 Phone <br /> TYPE OF WORK (Check) : 1 NEW WELL _;��DEEPEN RECONDITION f_1 DESTRUCTION /7 <br /> PUMP INSTZLAT I ION PUMP REPAIR 7PUMP REPLACEMENT— /7 <br /> Other, <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESPIT PRIVY <br /> SEWAGE DISP05AL, FIELD, CESSPOOL/SEEPAGE PIT. OTHER <br /> INTENDED,-USE : TYPE OF''WELL' CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable tool Dia. of --We <br /> ll- Excavation <br /> Domestic/private: Drilled Dia. of Weil Casing 60 <br /> Domestic/pub Driven' Gauge of Casing <br /> Irrigation ....Gravel Pack .Depth of Grbut SeAl.- <br /> Other A_ Rotdry Type 'of :Grout <br /> 3 Other Othdi Information <br /> PUMP INSTALLATION: Cdnti:actor <br /> � - Type of Pump s H.P. <br /> rume REPLACEMENT: State Work Done <br /> PUMP 'REPAIR: <br /> State Work Done <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 SanJoaquin Local Health District'— <br /> andithe State of. Cali?.orn'ia pertaining to or regulating well cons.truction. Within F.IFTEEN. DAYS <br /> after' completioii of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELT. DRILLERS REPORT- �k the well and notify them before putting the.well in use. The above <br /> information is true toy the best: of,:my.knowledge and belief_ <br /> 4,v <br /> SIGNED : TITLE <br /> IV (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> DATE '/V? <br /> ADDITIONAL COMMENTS.: <br /> P 1I #:GROUT INSPECTION L---" PHASF. III/FINAL INSPECTION <br /> INSPECTION BY....jzja2� 1P DATE � INSPECTION BY <br /> DATE <br /> t <br /> CALL FOR A GROUT, INSPECTION PR OR TO.. GROUTINGAND FINAL INSPECTION <br /> E H 4/72 1M <br />