Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> F Telephone: (209) 466--6781 <br /> APPLICATION FOR' WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7/-f- 41-r 1� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 2ZE_2e - <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 San Joaquin Local Health District. <br /> 4 <br /> JOB ADDRESS/LOCATION CENSUS TRACT' <br /> Owner e s Nance /� ��e�.� �G�F.r--r q_ -�L� Phone <br /> Address 7 7 City <br /> Contractor's Name P ,LA - License 4��2/.f`Q._Phone ,?7Ott <br /> z.r <br /> TYPE OF WORK (Check): NEW WELL '/'/./DEEPEN / / RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATIONS-/_/ PUMP REPAIR / / PUMP REPLACEMENT <br /> } Other <br /> E <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ' PIT`PR-IVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE E 0 WELL CONSVRUCTIQV SPEC FIC IONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing y <br /> 3 Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other_. Other Information <br /> PUMP INSTALLATION: Contractor ✓ dA!j-a, <br /> ,Type of Pump H.P. <br /> PUMP REPLACEMENT: / State Work Done 11 L gu <br /> PUMP REPAIR: / J State Work Done M <br /> .,2ESTRUCTION 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 /> t <br /> SIGNED � r �.1' TITLE <br /> (PR PL-OT-,PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I , <br /> i. APPLICATION ACCEPTED BY DATE oz <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSRECTION BY DATE INSPECTION BY DATE c16—IS' 71V <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING ANDjFINAL INS CTI <br /> E H 1426 / �^rf� 7/72 1M <br />