Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH- DISTRICT Oy a, D _V / <br /> FOOF.FI E USE: 1601 E. Hazelton Ave. Stockton Calif. // <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. j7 A l3-P r <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued - 7 ! <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 described. This application is made in�`cornpliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> ��'V2/ES T G � � CENSUS TRACT j� ' <br /> JOB ADDRESS/LOCATION -5-' ,E 666V4-•Q PEG ! <br /> !�"�M e 2 , Phone, <br /> Owner's Name ,,,�� -- _ <br /> Address 1PC4,L16-1?—. City <br /> San Joaquin Pump Co. 9.�0)'/ <br /> Contractor's Name License ��.2&3? Phone ' <br /> _ o. <br /> . 4. - <br /> Lodi, Calif icy 95240 - - <br /> TYPE OF WORK' (Check) : NEW WELL/ DEEPEN / / RECONDITION � ,DESTRUCTION /? <br /> PUMP INSTALLATION '/ / PUMP REPAIR //G//PUMP REPLACEMENT 17 <br /> 4 other l <br /> k <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 f <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 <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: + <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. 1 <br /> PUMP REPLACEMENT: / / State Work Done ~ <br /> PUMP-7REPAIR:; / T'—State Work Done 129&A I <br /> } <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 1 <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 FOR A GROUT INSPECTION <br /> PRIOR TO GR AND A FINAL INSPECTION. <br /> SIGNED TITLE San Joaquin Pump Co; <br /> DRAW PL T' PLAN 'ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY Lodi, Califarnio 95240 <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE , 17--2/-7?_ _ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III_/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY !` DATE <br /> c . , 3/76 2M <br /> E H 1426 Rev. 1-74 <br />