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 Issued <br /> (Complete In Triplicate) <br />;' ruct <br /> Application is hereby made to the San Joaquin Local Health District for a permit to con.),t <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 /> JOB ADDRESS/LOCATION 1911 S . ST. JOHN CENSUS TRACT : <br /> Owner's Name <br /> J.P. CAUDLE Phone 88-2404 <br /> Address SAME __ <br /> city ESCALON <br /> Contractor's Name T.D. SUTTON AND SON _ License # 279010 Phone838-2207 , <br /> TYPE OF WORK (Check): NEW,4WELL.. / /t:yDEEPEN / RECONDITION /_� DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT Aj <br /> Otherl 7 — <br /> DISTANCE TO NEAREST: SEPTIC TANK -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 /> k 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 C/j <br /> t Other Other Information �. <br /> I � N <br /> PUMP INSTALLATION: Contractor p <br /> y Type of Pump H.P. 5' <br /> PUMP REPLACEMENT: /%! State Work Done REMCVE' 2 H.P. JET AND INSTALL 2 H.P. SUB <br /> PUMP, REPAIR: - / / State Work Done r �w <br /> ESTRUCTION 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.. est of my" knowledge and belief. . <br /> kr _ <br /> f <br /> SIGNED TITLE PARTIM <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I' <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: /I All <br /> PHASE II GROUT INSPEC ION NAL INSPECTION <br /> ' D <br /> INSPECTION BY DATE INSPECTION BY ATE <br /> k CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> t E -H 1426 TJ72 1M <br />