Laserfiche WebLink
. SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO FFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued - 3 <br /> (Complete In Triplicate) c2/— VZO -j <br /> Application is hereby made to the San Joaquin Local Health District for a permit to con tract <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> Countyl..Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB AD RESS/LOCATION I r 0, t- -� CENSUS TRACT 447 <br /> Owner's Name f LL Phone .7;2 -..szlZ <br /> Address ( o City r <br /> r <br /> Contractor's Name i Lr-r License 4t� 19/o Phone. <br /> TYPE OF WORK (Check) : NEW WELL /-7 DEEPEN /-7 RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / NT PUMP REPAIR / / PUMP REPLACEME /-7 <br /> Other / / r-"% <br /> DISTANCE TO NEAREST: SEPTIC T K S h ft-R-L—IN-1 t PIT PRIVY W <br /> WAGE DISPOSAL FIELD CESSPOOL/SEEP GE P T OTHER <br /> INTEND U5E 9t?��% <br /> TYPE OF WELL CONSTRUCT-1.6"ECIFICNEAONS <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 Rotary Type of Grout <br /> Other Other Information <br /> f <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump kuy H.P. <br /> PUMP REPLACEMENT: %/ State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> cz�� <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. <br /> SIGNED <br /> r TITLE <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 II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY A6± DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 �,t,-' 1� 7/72 IM r <br />