Laserfiche WebLink
SAN JOAQUIN LOCAL TIEALTH DISTRICT <br /> FOFOFI+ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION'OR PUMP PERMIT Permit No. V- <br /> t <br /> 1 <br /> THIS. PERMIT EXPIRES l 'YEAR FROM DATE ISSUED Date Issued 1,-9-2a 7-.,- <br /> (Complete In Triplicate) 0,5-1- (2_0--,2 <br /> Application is --hereby,made-ito 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 /> opptyOrdinance No x.$_62 and ,, e R les -a Regulations n t San 'Joaquin Local Health District. <br /> Co <br /> �.E?:�'�`q"� ief � � f .•`g-��' <br /> '4 / <br /> JOB ADDRESS/LOCATION( � CEIQSUS TRACT <br /> Owner's Name �- - -4nPc � ;. Phone <br /> Address _ City - <br /> Contractor's Name <br /> ena _ License Phone:30-/ <br /> I <br /> TYPE OF WORK (Check) : NEW WELL ' DEEPEN '/ / RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /? i <br /> Other <br /> DISTANCE TO NEAREST-: SEPTIC TANK SEWER LINES PIT PRIVY <br /> . SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE,PIT OTHER <br /> INTENDED ..US.E - - 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 /> OtherOther Information <br /> PUMP INSTALLATION: Contractor �7 <br /> Type of Pump H.P. <br /> a <br /> PUMP REPLACEMENT: / / State Work Done j <br /> PUMP REPAIR: _ / / State Work Done <br /> .DESTRUCTION OF WELL: Well Diameter Approximate Depth w <br /> Describe Material and Procedure <br /> I hereby agree to complywith all laws and regulations of the San Joaquin Local Health District <br /> g q <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS j <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 kno edge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED, BYDATE 0.2 <br /> ADDITIONAL COMMENTS: T <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION.. ,, <br /> E H 1426 4/72 1M <br />