Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> }R OFFICE USS_: . 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Teleph6ne: (209) 466-6781 <br /> APPLICATION .FOR WELL CONSTRUCTION OR PUMA' PERMIT Permit No. ' L� <br /> THIS PERMIT EXPIRES 1: YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) �T <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 21692 E', Comstock Road CENSUS TRACT <br /> Owner's Name Demarti.ni-Gerlomes Phone <br /> Address P. 0. Bog 731,., Linden, Calif. 95236 City <br /> Contractor's -Name Linden Service Pumps License # Applied Phone 887-3696 <br /> TYPE OF WORK (Check) : NEW WELL /_7 DEEPEN RECONDITION /_7 DESTRUCTION /_7AL ` l <br /> PUMP INSTLATION /,-� '­PUMP PUMP REPAIR / / P1JMP REPLACEMENT /- <br /> Other <br /> DISTANCE TO NEAREST SEPTIC TANK SEWER LINES PIT PRIVY <br /> UnkncmnEWAGE <br /> (Replaced-old d Sp�,mn� DISPOSAL FIELD CESSPOOL/SEEPAGE- PIT OTHER <br />' INTENDED USE TYPE OF WELL T� CONSTRUCTION SPECIFICATIONS 00 <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 Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor Linden Service Pumps <br /> Type of Pump Submersible Pump H.P. <br /> F PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / 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 furni�sh..the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before'-putting the welkin use. The above <br /> information is true to the best of my knowledge and belief. <br /> SIGNED TITLE Partner <br /> {DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> ALI- <br /> PHASE I Ir <br /> APPLICATION ACCEPTED BY D TE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION INAL INSPECTION <br /> INSPECTION BY DATE INSPECTIO BY DATE f O <br /> f CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL N <br /> r E H 1426 7/72 1M <br />