Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> C. FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No: 73- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE_ ISSUED Date Issued <br /> 1 (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. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owners Name Phone • j <br /> Address `�j 4116 City 16SC oi✓ <br /> Contractor's Name License #,222010 Phone a D <br /> t - -- `� �- -4• ,�u.�}�4 �`V .. ��." .-�`°�,_1 -- �.. .rte_ - ^........- . .. . '_'-_ - - -- <br /> � TYPE OF WORK (Check) : NEW WELL / / DEEPEN / J RECONDITION /7 DESTRUCTION /-7 <br /> PUMP INSTALLATION '/ / PUMP REPAIR REPLACEMENT /-7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC: TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE F 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 'F Rotary Type}of Grout <br /> - Other Other Information 5 <br /> PUMP INSTALLATION: Contractor <br /> 4 Type of Pump H.P. <br /> PUMP REPLACEMENT: J / State Work Done <br /> 2' L :Ep/3J�L_ sJ/s <br /> `—Z?/ 'State-Work Done-'-,i <br /> � <br /> A <br /> I .DF.STRUCTION OF WELL.: Well Diameter Approximate Depth <br /> t ^ Describe Material and Procedure <br /> 3� <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. WithiA. 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 e <br /> information is true to the best of my knowledge and belief. <br /> SIGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR 'D MENT USE ONLY ti <br /> PHASE I t ` <br /> APPLICATION ACCEPTED B `� /7-, 0 , DATE IZ,�Z 23 <br /> ADDITIONAL COMMENTS: :y <br /> PHASE II GROUT INSPECTIONE FINAL INSPECTION <br /> INSPECTION BY DATE INSPEC -ION DATE <br /> CALL -FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br /> t <br />