Laserfiche WebLink
- SAN JOAQUIN LOCAL HEALTH. DISTRICT _ <br /> FO1~ OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif, <br /> Telephone : (209) .466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (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 Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name _ ZQ 6 Phone _jb1,f—62J7 <br /> 9 <br /> Address l.5. 3 -C, , D City GQOI <br /> -. San Joaquin Pump Co. Phone - a 7 <br /> Contractor's Name -(Division of Sn u• License # 3/Q37G a <br /> 711 N. S^Wrm;�imito St. i <br /> ;Lm;ii,sCcifi"areiia 95240 <br /> TYPE OF WORK (Check): NEW WELD/ / DEEPEN"/-'/ -RECONDITION- /-/, DESTRUCTION. /-7 i <br /> PUMP INSTALLATION /✓/PUMP REPAIR/ / PUMP REPLACEMENT /7 ..,. <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PITT OTHER <br /> PROPERTY LINE -• PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL . <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �• <br />` Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing �1 <br /> Domestic/public Driven Gauge of Casing {�}, <br /> Irrigation Gravel Pack Depth of Grout Seal k <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal` .Other,._, Other Information <br /> Geophysical-, Surface Seal Installed By: <br /> Z <br /> PUMP INSTALLATION: Contractor R! Lfl .� . <br /> TYPe;'of H.P. � <br /> I Pump % �. >.0 <br /> A <br /> t <br /> PUMP REPLACEMENT: / / ! State Work Done <br /> ..-State Work�-Done-. -- ^•.-. �..�-:r- -�,.�""" -., <br /> DES�TI��ICTION OF WELL: -'Weld[Ee_ter - " Approeimate Depth- <br /> _ DesAibaterial and Procedure <br />' I hereby 'tagree to comply wi h laws and regulations of the San Joaquin Local Health District <br /> and the StAlte 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 we tify them before putting the .well in.use. The above ! <br /> information is t' ue__to. the es of m knowled e and belief. I WILL CALL FOR A GROUT INSPECTION <br /> y g <br /> PRIOR TO GROUTING";AND A FINAL INSPECTION. <br /> 1-1 <br /> SIGNEDTIT <br /> . .' aLE Scan Joaquin Pump Co. <br /> RAW PLOT' PLAN ON REVERSE SID )` :, s !' „d <br /> FOR DEPARTMENT USE ONLY Lae:!, Ce':ifolvia 95240 <br /> PHASE I <br /> � <br /> APPLICATION ACCEPTED BY �. DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT' INSPECTION PHASE II FINAL INSPECTIO t <br /> INSPECTION BY DATE INSPECTION BY 'DATE <br /> .j1 1 / 7z�l <br /> 3/76:'r2M.- <br /> t E H 1426 Rev. .1-74 :` <br />