Laserfiche WebLink
FOs:OFFICE IFSE; SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. , Stockton, Calif. r , <br /> 1 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> �! THIS PERMIT. EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In Triplicate) Date Issued <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 <br /> Jo <br /> County Ordinance No. 1862 and the Rules and Regulations of the San JoaquinLocal <br /> Heath San trict. <br /> 1 JOB ADDRESS/LOCATION Health District. <br /> r <br /> s CENSUS TRACT <br /> Owner's Name M l�1 i Ib <br /> _ Phone ' 3 1- 77.x", <br /> Address �' 9 S Ga//ice <br /> Contractor's Name San Joaquin Puna CO. Y City <br /> - AQaRess License i Phone y7 <br /> n. eman_ --. <br /> Lodi, a i ornia <br /> TYPE OF WORK (Check): NEW WELL '/7 DEEPEN /? RECONDITION _ <br /> PUMP INSTALLATION / DESTRUCTION /� <br /> Other / / / REPAIR ./� PUMP REPLACEMENT f f <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES <br /> SEWAGEPIT PRIVY <br /> SEWA_GE DISPOS-AL FIELD i _ -�.._ <br /> �--•-- --- CESSPOOL:/SEEPAGE._PIT. w '..._-- - OTHER <br /> PROPERTY LINE- PRIyATE DOMESTIC WELL: <br /> INTENDED USE TYPE OF WELL PUBLIC DME IC WELL <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> Domestic/private r, _ Cable Tool Dia. of Well Excavation.�� Domestic/public Drilled Dia. of Well Casing <br /> Irrigation Driven Gauge of Casing — <br /> Gravel Pack Depth of Grout Seal <br /> Cathodic Protection �_ Rotary f <br /> Disposal - Type of Grout r <br /> Geophysical -,. Other Other Information ' ' <br /> -, Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type Of Pump <br /> _ <br /> PUMP REPLACEMENT: . H.P. <br /> State Work Done <br /> PUMP-,REPAIR:' s - <br /> Stat e-Work'Done" w <br /> --- t <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth f <br /> I hereby agree to comply with all Taws and regulations of the San Joaquin Local Heal y <br /> and the State of California pertaining to or regulating well construction. + <br /> after Completion of my work on a new well, I will furnish the San Joaquin Local th District <br /> Within FIFTEEN DAYS <br /> WELL DRILLERS REPORT of the well and notify them before gutting the..well in.use-. . .The above <br /> information is true to the,best -of- m Q 1 Health District a <br />'RIOR TO GROUTING AND A FINAL INS ECTz N owledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> SIGNED _� ��, S <br /> Il, TITLE an Joaquin Pum . <br /> r p Co. <br /> (DRAW P PLAN 0 REVERSE SIDE <br /> t <br />'RASE I FOR DEPARTMENT USE ONLY Lodi <br /> J'P A 'ION ACCEPTED BY . California 95240 <br /> ADDITIONAL COMMNTS: �C9Di� %A <br /> PHASE II G UT INSPECTION rs� u . "°`';-'nto b <br /> NSPECTION BY DATE PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE 27- <br /> E H 1426 Rev. .1-74 e 3 <br />