Laserfiche WebLink
f <br /> S;.i JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE —US-E-.----1 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL UINS'TRUCTION OR PVMJJ PERMIT Permit No. -r2_•i i'7 .'� <br /> THIS PERMIT- rYPIRES 1 YEAR FROM DATF ISSUED Date Issued g1".".'T-��_3 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to constrict <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 Jcaquin Local Health District. <br /> JOB ADDRESS%LOCATION I,Z (/'L. f- ��r, E � .. 11,-I✓,-,I Ut-t-•% �_ CENSUS TRACE _ <br /> Owner's Name t./�c^ ^�.�C,�.y( /c(e-ju=-^ �� Phone '7)7- <br /> Address - '70 qtr—/..t ? City <br /> Contractor's Name License P1T/'� , Phone 17 Jf <br /> TYPE OF WORK (Check): NEW WELL /f DEEPEN /% RECONDITION /_% DESTRUCTION /-] <br /> PUMP INSTALLATION /—!—PUMP 5 <br /> PUMP REPAIR !A' PUMP REPLACEMENT /-7 <br /> Other _ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEW::d LINES PIT PRIVY V <br /> SEWAGE DISP05AL Fa ULD CESSPOOL/SEEPAGE PIT OTHER C <br /> INTENDED USE ' TYPE 0- WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/priva.te Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> _ Irrigation Gravel Face Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor %r./•-- t f'//( [_.• _ .L,:-, <br /> Type of Pump H.P. 1c'7 <br /> PUMP REPLACEMENT: / / State work Done---------'�'---"""��£• <br /> PUMP kEPA1R: /� Seacc Wozk Rune <br /> DESTRUCTION OF WELL: Well Diameter __ fit / 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 any knowledge and belief. <br /> / F ( l <br /> SIGNED f?y °rl �1 �i ..4_ e - � ! TITLE <br /> (UR%W PLOT PLA'; ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I - <br /> APPLICAT:ON ACCEPTED BY�izj .--// _ DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPFC11ON PHASE III%FINAL_ INSPECTION <br /> INSPECTION BY DATE _ INSPECTION <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTINr AND FINAL INSP CTION. •_�, <br /> E H 1426 7/72 1M <br />