Laserfiche WebLink
e zf SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Po_" <br /> OFFICE USE: !: 160.1 E. Hazelton Ave. , Stockton, Calif. <br /> j. <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 11ealth 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 Dvr otic ;, -,eve <br /> ���� Y sa `T�' "� L"`fr•� <br /> ��`"' �� "'t CENSUS TRACT _ <br /> Owner's Name C t4 2 L ih P"L L.a I-e 6� - 6 Y3 <br /> Phone i <br /> Address /42 A)� A L 6'i.c+ -7 t� <br /> City G vim% <br /> Contractor's Name Son Joaquin purm") Cc, <br /> l License # 2ASdj Phone <br /> TYPE OF WORK (Check): NEW ' CaI. EQ 912, <br /> ( L D E16 /? RECONDITION /? DESTRUCTION /? <br /> / <br /> PUMP INSTALLATION / / PUMP REPAIR/—/ PUMP REPLACEMENT <br /> Other / — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> SEWAGE DISPOSAL FIELD PIT PRIVY <br /> PROPERTY LINE - PRIVAT DOE MESTICSWELL�SEEPAGE PUBLIC DOMESTIC WELL, <br /> INTENDED USE TYPE OF WELL <br /> Industrial CONSTRUCTION SPECIFICATIONS f <br /> 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 <br /> —Disposal Other <br /> Geophysical Other Information <br /> Surface Seal Installed By: \ <br /> PUMP INSTALLATION: Contractor L1 <br /> Type of Pump <br /> PUMP REPLACEMENT; / State Work Done <br /> Itis;.1/i Ve,"{ &tjj;?5,__ p.,, ] a Dv <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <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 furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the .well in use The above <br /> information is true to the best of my.knowled a and belief, <br /> B I WILL CALL FOR A GROUT <br /> PRIOR TO GROUTING AND A FIN INSPECTIO INSPECTION <br /> SIGNED <br /> TITLE son Joaquin -Emp <br /> (DRAW PLOT PLAN ON REVERSE SIDE} hur c�.j <br /> FOR DEPARTMENT USE ONLYSprrrnnnra <br /> PHASE I <br /> Lodi, 9.� �ar�,:c �2 <br /> APPLICATION ACCEPTED BY � � <br /> ADDITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTION PHASE III FINL IN <br /> ASPECTION <br /> INSPECTION BY DATE <br /> INSPECTION BY C- 13 . DATE <br /> E R 1426 Rev. 1-74 <br /> 6/7K 9m <br />