Laserfiche WebLink
_ 1 <br /> qg <br /> _ SAN JOAQUIN LOC,'%L .1HALTH `a STRICT <br /> 160'1. L?. Hazelton Ave. , Stockton, Calif. <br /> alephone: (209) 466-6781 <br /> PLICATION FORWELL, CONSTItJCTION- Olt -PUMi' PEIL`1T Permit No. <br /> q g 5 6 b <br /> THIS PERMIT EXPIRES .1 YEAR I'RON '.7.T.", ISSUED Date Issued 6 <br /> y (Cbmplete. In Triplicate) <br /> plicatipn 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-tan-Joaquin <br /> Count%- Ordinance No. 1862 and -the Rules�and.'•Regulations of the San Joaquin Local Health District. <br /> g rs <br /> 4., j0B ADDRESS/LOCATION CENSUS TRACT` <br /> x <br /> ' owner's Name F Phone <br /> Address _`__ S T - city. <br /> Contractor's Name +. .( �' a License !i `1�LGZPhone 2-SS 7 <br /> A li. <br /> *..Y.:" TYPE OF WORK (Check): 'NEW WELL DEEPEN /7 - RECONDITION /-]r DESTRUCTION. l7 <br /> PUMP INSTALLATION PUMP.REPAIR l . :PUMP REPLACEMENT f7 Er <br /> .; Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY I` <br /> xj f. <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE F. <br /> _ TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> }u Industrial Cable Tool Dia. of Well Excavation ;. <br /> Domestic/private Drilled Dia. of .Well Casing L <br /> Domestic/public `Driven Gauge of Casing y <br /> /irrigation Gravel Pack Depth of Grout Seal Cr <br /> OtheryRotary Type of Grout <br /> 0th�.r Other Information F <br /> PUMP INSTALLATION: Contractor K <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: State Work Done <br /> E DESTRUCTION OF WELL: 'Well Diameter <br /> Approximate Depth. <br /> Describe Material and Procedure. <br /> I hereby agree to comply with all laws•antregulations 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 /> DRILLERS REPORT of the well. and notify them before putting the.well in use. The above' <br /> informacioon--ids true to the best of my knowledge and belief. <br /> TITLE <br /> PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY k , <br /> ? .,0 N ACG�`OT BY �.vv: <br /> �} i � DATE � �' 9j, <br /> PHASE .11 CROUT INSPECTION PHASE TTI FINAL INSPECTION <br /> ..YY — -- -DATE _ INSPECTION BY DATE -j <br /> ;T INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> 4/72 1M <br />