Laserfiche WebLink
17-1 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> :FOR OFFICE USE: � 1.601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> I <br /> LIGATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -72.. !Z2- <br /> THIS <br /> 72.. y2THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued ✓5 IZ-7�i <br /> (Complete In Triplicate) 1"y 13 6 <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/oar 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 13So l r <br /> r � _t Li�,���r _-- -%Lf7f� LU_•� l��rY�-r1 CENSUS TRACT :?-SS-310,2-4 <br /> Owner's Name OIL u 2a sem^ _ Phone - <br /> T"r� <br /> Address / , ,_ City <br /> Contractor's Name �� G1-4$ (°� (� �, �„ , iti,� ,` License �P Phone LO <br /> . W <br /> 4-1 <br /> -TYPE-OF-WORK (Check) , NEW WELL DEEPEN /_/ RECONDITION /-7 DESTRUCTION /7 <br /> PUMP INSTMATION / / PUMP REPAIR I I PUMP REPLACEMENT /7 <br /> Other / / , <br /> DISTANCE TO NEAREST: SEPTIC TANK U± SEWER LINES ,•fir 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 Casing6 -SXy <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal o <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor � . s <br /> Type of Pump fi„ �. .,,f H.P. / <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / 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 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 neer 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 /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY _ / � DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE 14 GROUT INSPECTION !:;TSa4LII//FINAL INSPECTION <br /> INSPECTION BY,, DATE - INSPECTION BDATECALL ]AOR A T INSPECTION PRIOR TO GROUTING AND FINAL INS ION. <br /> E H 1426 4/72 1M C� <br />