Laserfiche WebLink
+a `/ <br /> ti <br /> S:.N JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE---I 1601 E. Hazelton Ave., Stockton, Callf. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CnNSTRUCTION OR PITMP PERMIT Permit No. -7'Z-'i;7 <br /> r <br /> THIS PERMIT T:%PIRES 1 YEAR FROM DATF ISSUED Date Issueds''.', <br /> %Complete In Triplicate) <br /> Application is hereby made to the San Jo..quin Local Health District for a permit to construct <br /> and/or Install the work herein described. This application is made in compliance with. San Joaeuin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District.JOB ADDRESS/LOCATION y r 'P -,_.: -z_ CENSUS TRACT <br /> Owner's Name 1 -.rrC;a,1,j Phone 72 f- Syl <br /> Address /;t 70_.Z(� City <br /> Contractor's Name �..._/.,-.-, �_ License d/l/'G , PhoneJi?1 J�(Y,(� <br /> TYPE OF WORK (Check): NEW—WELL-/F%- DEEPEN-/-/ RECONDITIO��N /7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR 'A' PUMP REPLACF.MEN'I /7 <br /> Other / / .-. <br /> DISTANCE TO NEAREST: SEPTIC TANK SEW::d LINES PIT PRIVY <br /> SEWAGE OffiPO$AL FiELU CESSPOOL/SEEPAGE PIT OTHER C <br /> INTENDED USE WELL CONSTRUCTION SPECIFICATIONS <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 Pace Depth of Grout Seal <br /> Other . Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATIONe Contractor %sr/•_� ,(,,. - �f',,,/-_ /L.[�. ,, <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done n <br /> PUMP REPAIR: 157 Sta.e Work Done <br /> -tri. ` 1. <br /> DESTRUCIION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 1 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 �Ct /t t i ,(K. l- TITLE C' <br /> (ORAL' PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARfMENT USE ONLY <br /> PHASE I - -- <br /> APPLICAT:ON ACCEPTEDBY i j -:.�"� DATE , -6 -2,3 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPF.CTI01: PHASE i�Ill ;F—INA-L_ INSPECTION <br /> INSPECTION BY DATE - INSPECTION H1', �''' DATE -V�i_7.4 <br /> CALL }OR A GROUT INSPECTION PRIOR TO GROUTINP AND FINAL INSt'�:CTION, <br /> E H 1426 7/72 1M <br />