Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: „ f� 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--5751 <br /> # LIGATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ? 2- 5t rj <br /> HIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application,:is hereby%Zade 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 andl.the Rules and Regulations of the .San Joaquin Local Health District. <br /> i �r <br /> JOB ADDRESS/LOCATION sj-�2C7 CENSUS TRACT ' <br /> i}�� �.�...,.,._� ��,.__. <br /> � F <br /> Owner.' .Nameay ,�,lp�¢.' t, . Phone _- _- �?p3 <br /> Address <br /> XC. __ _ ... City <br /> C~Con ractor's Name ��.y, �,�L y, � �C ao� 1,�4� License ��� j� Phone <br /> TYPE OF WORK (Check) : NEW WELL/% DEEPEN /% -RECONDITION / I DESTRUCTION /`7 <br /> PUMP INSTALLATION '/ / PUMP REPAIR '/ / PUMP REPLACEMENT J ` <br /> Other ./ / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial I Cable Tool Dia. of Well Excavation <br /> Domestic/private I Drilled Dia. of Well Casing <br /> Domestic/public .1 Driven Gauge of Casing <br /> Irrigation A , Gravel Pack Depth of Grout Seal <br /> Other f Rotary Type of Grout a <br /> Other Other Information ' , <br /> f <br /> PUMP INSTALLATION: Contra- <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: r /- / State Work .Done <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 ori 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 /> informatio i true to the best of my knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FO EPARTMENT USE ONLY <br /> .PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: , <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION y <br /> INSPECTION BY DATE INSPECTION BY DATE 5-A 0 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING ANIS FINAL INSPECTION. Y <br /> E H 1426 4/72 1M <br />