Laserfiche WebLink
SAN JOAQUIN ,LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> ' Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1'YEAR FROM DATE ISSUED Date Issued4i 72 <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 made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the <br /> San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION W,rl dl,le 0-*-- ;910Dl9- douAx olyn CENSUS TRACT <br /> Owner's Name lop NleI'G (, i* Phone t�[�3 —44KI,6 <br /> Address / " / n tJ City <br /> Contractor's Name ���o,// v License 11y�"Phone }- <br /> TYPE OF WORK (Check): NEW WELL /-7 DEEPEN /-7 RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION /—/ PUMP REPAIR Z PUMP REPLACEMENT /7 <br /> Other /-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK µ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <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 Vi <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor -y� / !► ,ro"' <br /> Type of Pump r-ID72164 A H.P. t4d <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done eo AOIX u / 4j pec <br /> d s+f� 12/re-,"A <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 m know ed belief. <br /> SIGNED cte ITLE PSI <br /> fbRAP PLOT PLAN ON REBERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I " <br /> APPLICATION ACCEPTED BY DATE = "7'�.�. <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P I7 FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION Bim- DATE rd�Z�-72- <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M co <br />