Laserfiche WebLink
SAN JOAQUIN LOCAL, HEALTH DISTRICT <br /> FOR OFFICE USE: � 1601 E. Hazelton Ave. , Stockton_., Calif. <br /> Telephone: (209) 466 67$1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PIWI PERMIT Permit No. 72,`5 S <br /> 1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM;.DATE ISSUED Date Issued <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 t <br /> ,.County..Ordinance No1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 3= Mile South of Mttlemen at end of Lj6 Road CENSUS TRACT ' <br /> & j mile st of.Atkins <br /> Owner's Name ftmeS.Burnett J` Phone .368.3922 <br /> ` Lodi <br /> Address 22220 N. HWy 99, AsaMPos. Calif* City <br /> Contractor's Name Purvianee.DrS. ers License # 2,0707 Phone 931-"68 <br /> TYPE OF WORK (Check)t. NEW WELL '/a/ DEEPEN %/� RECONDITION /_/ DESTRUCTION_/—T <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT /-7 <br /> Other. / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY Oa <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial A % Cable Tool Dia. of Well Excavation 6n <br /> Domestic/private t Drilled Dia. of' Well Casing 6" <br /> Domestic/public ! Driven Gauge of Casing 6R ate <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> -Other Rotary Type of Grout -- <br /> Neat Gemeft_:6— <br /> Other Other Information. ' <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / /` ,State Work Done <br /> PUMP REPAIR: /7 State Work Done <br /> i .DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i. 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 /> I 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'�alfid belief. <br /> SIGNED ? T TITLE Partner <br /> (DRAW PLOT -PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE .I r ' Q �t <br /> APPLICATION ACCEPTED BY DATE L" IoZ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUTINSPECTION PHASE I / AL INSPECTION <br /> INSPECTION BY jV >.DATE INSPECTION BY DATE/O- '7 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />