Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTIi DISTRICT <br /> FOR OFFICE USE: 1.601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781. <br /> ' P ICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z L- 3 0 3 <br /> THIS PERMIT EXPIRES 1 YEAR MOM DATE ISSUED Date Issued 4- z-5--7z, <br /> i - - -- (Complete In Triplicate) <br /> Application is hereby .made-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 Or 1862 and-the Rules -and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION `�`��?,S '� (� y , �! CENSUS TRACT __ <br /> Owner's Name •'' GaLcc S, J. 1�oTC + A 15 S - - Phone <br /> Address PacU,- - - City <br /> ' <br /> Contractors Name 4' <br /> _ _ �~2A11Y�(.r - CC]I_� JIUC License #Q5j,�'gQ Phone <br /> TYPE OF WORK (Check) : V NEW WELL / / DEEPEN/_/ RECONDITION f DESTRUCTION /-7 <br /> PUMP.INSTALLATION '/ / PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK Q' SEWER LINES` PIT PRIVY --- <br /> SEWAGE DISPOSAL FIELD j/L) CESSPOOL/.SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPEC FICATIONS <br /> F Industrial Cable Tool Dia. of Well Excavation// <br /> )( Domestic/private �1,_ Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing. _/ / •/2 /- 4 <br /> n <br /> IrrigatioGravel`Pack - Depth"of�Grou'tea <br /> Sl <br /> _ v1 <br /> Other Rotary Type of Grout <br /> Other Other Information ' `--� <br /> r <br /> PUMP INSTALLATION: Contractor <br /> f Typelof Pump -. � � - - - H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR:m- --« l/=/ 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 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 /> i information is tr e'_?o theY6st o owledge and belief. <br /> SIGNED V,/ TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 07 <br /> APPLICATION ACCEPTED B DATE <br /> ADDITIONAL COMMENTS: <br /> PHAS I OUT, INSPEC ON PHA I,II/FIN INSPECTION <br /> INSPECTION BY DATE INSPECTION BY i DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPE ON. <br /> E--H,.1426 - - 4/72 im a <br /> Y <br /> ` I e <br />