Laserfiche WebLink
__��_ SAN JOAQUIN LOCAL HEALTH DISTRICT . <br /> B.O9 'OP'FICE 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. y7y-Z <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 des.crib.ed. 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,�;ST.S i Y- iJTsk`a,�lrfPiPr� / CENSUS TRACT <br /> Owner's Name vla CS Phone <br /> 7zZ `s z <br /> Address 2 ._ G City .SiJCl77 .�i7o . <br /> Contractor's Name Sop Joaquin PUOP CG- License # 3 Phone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION /_/ DESTRUCTION <br /> PUMP INSTALLATION /ZW/ PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST': SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT _ OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE ji TYPE OF WELL CONSTRUCTION SPECIFICATIONS <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 /> Cathodic Protection Rotary Type of Grout CIGDisposal '� Other Other Information pati <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor dA CE eC) COD/ <br /> Type of Pump H.P. �',[ /•G/�- <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP- REPAIR: - - ,W / / 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 k <br /> and the State of California pertaining to or regulating well "construction. Within FIFTEEN DAYS f <br /> after completion of'`my work on a new well., I will furnish the San Joaquin Local Health District a + <br /> WEIl;;,- KILLERS REPORT of the well and notify them before putting. the well in use. The above <br /> information is true ;to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION R <br /> PRIOR TO GROUTING AND A INSP CT - " NFAA_ + <br /> SIGNED A TITLE San JOCq€tin FulTip CO. <br /> (DLOT PLAN ON REVERSE SID rasion o an Jnnquin 5Ltp;,;;. C�.) <br /> FOR DEPARTMENT USE ONLY Ph ° <br /> PHASE I <br /> Lodi, California 95240 <br /> APPLICATION ACCEPTED BY DATE ��QT <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION _ <br /> INSPECTION BY DATE INSPECTION BY DATE (9- j %`,P <br /> E H 1426 Rev. .1-74 <br />