Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE`tSE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-67$1 i <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.zj-3 S <br /> i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ? �.P-73 <br /> (Complete In Triplicate) <br /> Application 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 San Joaquin.• <br /> County Ordinance No..-0-186-2and the Rules and Regulations of the San Joaquin Local Health District. <br /> low <br /> JOB ADDRESS/LOCATION _ g!� CENSUS TRACT C 4'�_2*Q-o3 <br /> Owner's Name ��� �O.0�9/i� - - -- - - Phone <br /> I <br /> Address City /�r. GS <br /> Contractor's Name 6LA_lz///1/Yi z5,62".- <br /> License 46 %/G„ ,? Phone �a� <br /> YTYPE OF WORK (Check) : NEW WELLDEEPEN / / RECONDITION /7 DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other O¢ <br /> rQ <br /> DISTANCE TO NEAREST: SEPTIC TANK � `" f SEWER LINES Q A_ PIT PRIVY <br /> SEWAGE DISPOSAL FIELD C SE SPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> i <br /> 77- <br /> Industrial Cable Tool Dia. of Well Excavation _ /Q <br /> Domestic/private Drilled Dia. of Well Casing (p '� _ jE <br /> Domestic/public Driven Gauge of Casing, <br />� . Irrigation Gravel Pack Depth of Grout Seal <br /> Other F✓ Rotary Type of Grout <br /> Other Other Information <br /> F Ll <br /> i <br /> PUMP INSTALLATION: Contractor <br /> Type of Pu H.P. } <br /> PUMP REPLACEMENT: f / State Work Donee <br />"'PUNT'REPAIRo—_ <br /> �. .. ..� sem.. <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 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 knowledge and belief. C <br /> k SIGNED <br /> RAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE I TIO PHASE JII FINAL ZSPECVION <br /> INSPECTION BY MATE INSPECTION BY DATEI-7 <br /> CALL FOR A GROUT .INSPECTION PRIOR TO GROUTING AND FINAL INS ION, <br /> E H 1426 7/72 1M <br />