Laserfiche WebLink
I ! SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permito. ZZ-5 i_7 <br /> THIS PERMIT EXPIRES 1 YEAR`FROM DATE ISSUED Date Issued ?1/ <br /> f (Complete Iii Triplicate) <br /> Application is, hereby made to <br /> the,San Joaquin Local Health District for a <br /> 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 ,52 <br /> � .rte, <br /> Owner's Name - -- - y �'.._l'i@�d Phoneoa? <br /> { <br /> Address -S/A City <br /> Contractor's Name C'11`h 3 License # Phone ' <br /> TYPE OF WORK .(Check): NEW WELL "/K/ DEEPEN /-7 RECONDITION /? DESTRUCTION /-7 V <br /> PUMP INSTALLATION / / " PUMP REPAIR/ / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK fte SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD /per CESSPOOL/SEEPAGE PIT OTHER -- <br /> ' 1 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private ,( Drilled Dia. of Well Casing ,yl <br /> Domestic/public Driven Gauge of Casing q N <br /> Irrigation ravel-Pack—'° D-ep-th of Gro` -u-V-S6a-1 <br /> Other ` Rotary Type of Grout r <br /> ;n Other Other Information . <br /> .H r <br /> PUMP INSTALLATION: Contractor .» <br /> M Type of" Pump H.P. (� <br /> .PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ' tea <br /> ;DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply withl.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 i <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above i; <br /> information is true to the est of my knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE' SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 6-11-7-z--- <br /> ADDITIONAL COMMENTS: V - <br /> PHAS II GR NSPECTION PHASE II/FINAL INSPECTION # <br /> INSPECTION BY DATE - 3.p 2r INSPECTION BY DATE <br /> CALL FOR AROUT INSPECTION PRIOR TO GROUTING AND FINAL INSP ION. <br /> E H 1426 4/72 1M <br /> C i <br />