Laserfiche WebLink
SAN,JOA-QUIN LOCAL HEALTH DISTRICT <br /> FOND OF?ICE USE: 1 ` �Hazelton Ave. , Stockton, Calif s <br /> Telephone: (209) 466-6781 <br /> APPLi CATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7Z- e Z <br /> i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued `=7 of <br /> r (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct j <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. i <br /> JOB ADDRESS/LOCATION 0 Z CENSUS TRACT ' S�. <br /> Owner'$ ;Name-. <br /> - 1 ,��_ f7l��. �3 .. ..,. Phone <br /> Address YG City i <br /> i <br /> Contractor's Name &N i Y. 6 &D Drill,'=4 LOQ. IPVeQ� License # ///,,3 Phone -,S'"� �- S6y� <br /> S <br /> ..TYPE-OF--WORK-(Check) : NEW' WELL /"''DEEPEN / % RECONDITION / / DESTRUCTION /? j <br /> PUMP YNSTMATION / / PUMP REPAIR / / PUMP REPLACEMENT /_ ! <br /> Other / / <br /> 1� <br /> DISTANCE TO NEAREST: SEPTIC# TANK SEWER LINES PIT PRIVY 1 - <br /> SEWAGEi; DISPOSAL FIELD CESSPOOL/SEEPAGE PIT i OTHER <br /> INTENDED USE TYPE OE- WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial } Cable Tool Dia. of Well Excavation ! <br /> Domestic/private } .. y Drilled Dia, of Well Casing <br /> Domestic/public I Driven Gauge of Casing _ <br /> Irrigation € Gravel Pack Depth of Grout Seal I <br /> Other Rotary Type of Grout f <br /> Other Other Information ' i <br /> PUMP INSTALLATION: Contractorl"I' Ptiorf ric An# ` <br /> -Type of Pump` H.P. <br /> k,� I . 4 MANTECA. CALIF:GM0 7 sG <br /> PUMP REPLACEMENT: / / State Work-Done <br /> PUMP REPAIR* / / State Work Done <br /> ,DESTRUCTION OF WELL: Well Diameter s 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. 1 Within FIFTEEN DAIS <br /> after completion of my work on anew well,. I gill 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 /> e <br /> information is true to th best of my knowledge and belief. <br /> li <br /> i <br /> SIGNED TITLE <br /> -71 DRAW YLOT PLAN ON REVERSE SIDE) <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTRD_BY / DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION y' PHASE I I/FINAL INSPECTION <br /> 'JNSPECTION BY DATE INSPECTION BY DATE ,-Zb- 2-- <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426-• - 4/72 1M <br />