Laserfiche WebLink
J SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOP, OFFICE USE: ' `�T 1601 E. Hazelton Ave. , Stockton, Calif. A <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,7S- -)O A4/Q <br /> /� THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -fSJS <br /> �t{�C (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 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 /> q00 .* /va&TN VtOF of Pec,rier- Ro i/3 M,k- i✓ASr <br /> JOB ADDRESS/LOCATION CENSUS TRACT Qp3- 05o_13 <br /> Owner v s Name f N e, fe m r,, Phone 3 <br /> Address I;k 4F Lupe C 716 2 City Cool <br /> Son Joaquin Pump Co. <br /> Contractor's Name Jklyision of Sae 1--_500 License Phone <br /> E. Ke <br /> ttlem <br /> Lodi, a ifornin 95240 <br /> TYPE; OF WORK (Check) : NEW WELL /? DEEPEN '/_7 RECONDITION /-7 DESTRUCTION /7 � <br /> PUMP INSTALLATION /_/ PUMP REPAIR /—/ PUMP REPLACEMENT J <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 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 ft1 <br /> Irrigation Gravel Pack Depth of Grout Seal � + <br /> Cathodic Protection Rotary Type of Grout p� <br /> Disposal Other Other Information <br /> Geophysical <br /> Surface Seal Installed BY: _• <br /> PUMP INSTALLATION; Contractor C <br /> Type of Pump H.P. , <br /> PUMP REPLACEMENT: 97 State Work Done IouS-"6 L_- - /4 � � 7:QQ/trE„ i�V 4JGLL_ <br /> PWM REPAIR: /7 State Work Done <br /> ES•TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure - <br /> I hereby agree to comply with all laws and regulaelons 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 knowledge and belief. I WILL CALL FDR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. m rump 1,o. <br /> SIGNED _ _ 1�-/r %['t-•-f r12� TITLE A-RybiOn of San Joaquin surphur Co.) <br /> (DRAW PLOT PLAN ON REVERSE SIDE emQn <br /> ttdp <br /> FOR DEPARTMENT USE ONLY WIM11110 -:)4W <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 6 -/ <br /> lE H 1426 Rev. 1-74 1-74 2M <br />