Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR aFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 72- - 7 ? <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued Z Z T 7 7/ <br /> (Complete In Triplicate) zs7.-. 2-3p-off' <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. <br /> 862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> OAJ <br /> JOB ADDRESS/LOCATION A1 CENSUS TRACT S-50 <br /> Owner's Name L. i NC19 1. D, Phone <br /> Address ���< E _ DNi._ — _.,_. _...,..._.__ City t} <br /> Contractor's Name N/n6S RR 0-5 , - License # Phone <br /> TYPE OF WORK (Check) : NEW WLL ',M DEEPEN ,/ / RECONDITION / t DESTRUCTION <br /> PUMP INSTALLATION PUMP REPAID %// PUMP REPLACEMENT ' �/7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK � SEWER LINES moi- PIT PRIVY NO � <br /> SEWAGE DISPOSAL FIELD d — CESSPOOL/SEEPAGE PIT &&& No o Aye <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial, ' Cable Tool Dia. of Well Excavation <br /> Domestic/priva-te_, _ ._ - DrilledDia, of Well Casing fj .� <br /> Domestic Dia. <br /> `Driven Gauge of Casing — <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> er Rotary Type of•.Grout, r r (a <br /> r• <br /> Other Other` nformati6n <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done � ? • <br /> i <br /> ,DESTRUCTION OF WELL: Well Diameter j7—_. z 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. <br /> SIGNED T-LTLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEP T -USE ONLY -v <br /> PHASE I [ ! i, l � <br /> APPLICATION ACC TED BY DATE 7'20r 72, <br /> ADDITIONAL COMMENTS: <br /> P ROUT INSPEC ON. P E INAL INSPECTION <br /> INSPECTION BY- .. , ., _,DAT-E' j INSPECTION'BY <br /> a ' DATE Z3 <br /> CALL FOR A GROUT INSPECTION PRIOR•T0 GROUTING AND FINAL INSPEC ION. <br /> E H 1426 4/72 1M <br />