Laserfiche WebLink
/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE US 1601 E. Hazelton Ave. , 'Stockton, Calif. <br /> Telephoned (209) 466-6781 <br /> APPLICATION FOR WE1,L CONSTRUCTION OR PUMP PERMIT Permit No..k <br /> THIS PERMITPEXP1RES 1 YEAR FROM DATE ISSUED ` Date Issued 8 /0 3 <br /> ' [/ c� �-3 ` -c µ �Ett¢r2c�✓ /�U `a(Complete"In Triplicate) , <br /> Applieatio'n is hereby -made to the'San Joaquin Local,.Health District for a permit to construct <br /> d/or install the work herein described. This application is made in comphance'ki'th San Joaquir <br /> �unty Ordinance No. 18662 and the Rules and Regulations• of the San 'Joaq ' ' 'c" ' Health District. <br /> JOB ADDRESS/LOC TION`18 <br /> yY�� O�DCENSU5 TiiACT ' <br /> o:. c Ph• one <br /> Ler Is Name . nn <br /> g <br /> / .. .• _ C.i.ty �l.C9mnru.� . <br /> dress <br /> License a Phone <br /> lontractor's Name VULL <br /> __ - _ -_ =—�T" <br /> PE OF WORK (Check): NEW WELL /x/ DEEPEN / / RECONDITION DESTRUCTION DESTRUCTION /-T <br /> PUMP INSTAL TION /—/—pump REPAIR / / PUMP REPLACEMENT /7 <br /> Other /-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> G <br /> SEWAGE DISPO FIELD CESSPOOL/SEEPAGE PIT OTHER Pfi <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> + Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public <br /> Driven Gauge of Casing <br /> Ixrigatlon Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout _.7.f2 <br /> Other- Other Information <br /> I 1 <br /> *UMP INSTALLATION: Contractor._- . H,P <br /> Type ofY Pump i <br /> C-RLP <br /> REPLACEMENT: ' 17"'state Work Done <br /> ALR: 1 I State Work Done•.. <br /> f <br /> .�- � - - <br /> �ESTRUCTION'OF WELL: Well Diameter - -•-'� Approximate Depth� <br /> Describe Material and Procedure <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> [and the State of California pe.rtainingtto 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 : <br /> WELL DRILLERS REPORT of 'the well and notify them before putting the well in use% The above <br /> 'information true to the be of my knowledge and belief. <br /> TITLE <br /> SIGNED r <br /> (D PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE _ DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE III INAL INSPECTION <br /> PHASE II GROUT INSPECTION <br /> INSPECTION BY DATE -/fl '73 INSPECTION BY _ DATE / <br /> CALL FOR A GROUT•INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. x, 7/72 1M ` <br /> E H 1426 <br />