Laserfiche WebLink
JSAN JOAQUIN LOCAL HEALTH DISTRICT <br /> . FF 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 AN 18 197 <br /> ' t �for7 !)"-.,9)A-vtS';90: (Complete In Triplicate) 14?a^J -. 6a- Yeo--o/ <br /> ' Application"is hereby made' to the San Joaquin Local Health District for a permit to constr t <br /> and/or install the work herein described. This application is made in compliance with San, Joaquir <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIONe4J 4k2,0 ,e CENSUS TRACT <br /> Owner's Name 2 SCF Phone <br /> Address City /77 -tjQa� <br /> - <br /> Contractor's Name an ,Joaquin Pump Co. License Phone3 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / 1j RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION / PUMP REPAIR /—/ --PUMP <br /> PUMP REPLACEMENT /-7 i" <br /> Other <br /> ' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY •cl <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. , o'f 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 /> Cathodic Protection Rotary Type of Grout ' <br /> Disposal -- Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor . rte► (��, <br /> Type of Pump "r H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP TREPUk,. .- _ /7 State Work Done <br /> DES-TRUCTION OF WELL: Well Diameter .Approximate Depth <br /> f. 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'constructi.on. 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 puttingthe- well in use. The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> f PRIOR TO GROUPING NAL,..INS EC O <br /> 4 SIGNEDAc TITLE San Joaquin Pu`m C <br /> (DRAWILOT PLAN ON REVERSE SIDE) f11sion o San Jogquia$ufphur C <br /> Gj <br /> OR DEPARTMENT USE ONLY OULraMento t. <br /> PHASE I Lodi, California 95240 <br /> APPLICATION ACCEPTED BY DATE r <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPEC N PHAS I/FIW INSPECTION <br /> INSPECTION BY DATE INSPECTION DATE <br /> E :H 1426 Rev. - I-74 b/7.7 _ 2M <br />