Laserfiche WebLink
C/0 SAN JOAQUIN LOCAL HEALTH^DISTRICT J <br /> FOF:~-OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77 'a <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -2,2 <br /> (Complete In Triplicate) <br /> Application is Hereby made to the San Joaquin Local Health District for a permit to construct. a <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 /> S'ou7"11 or KCr-77 .-"^0 Ln1 f WAST Sint OF <br /> JOB ADDRESS/LOCATION CENSUS TRACT ` j <br /> Owner's NameSr�n? Phone 3� <br /> Address / x,235 /!/., 1/!.0;/j s; �ee_> --- City GCSU/ - <br /> 5,,in locquin pump L;0- <br /> Contractor's Name ton uin Sulphur col License # 67,? Phone <br /> 369 Z/ <br /> Sa,-rcomento 5t. <br /> L;odi,-Cajifarnici 952t <br /> TYPE OF WORK (Check) : NEW WELL/-7 DEEPEN %/ RECONDITION ,/ / DESTRUCTION /-7 �- <br /> PUMP INSTALLATION/ / PUMP REPAIR /a:^PUMP REPLACEMENT /-7 <br /> Other <br /> i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PTT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENNDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS Rs.j <br /> Industrial Cable Tool Dia, of Well Excavation CSI <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 Y Surface Seal Installed By : \� <br /> PUMP INSTALLATION: Contractor \, <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done } <br /> PUMP .REPAIR: State Work Done yFgalzz Zr A/za X.6Rl426- !d <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 <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 GROUT D A FINAL INSPECTI Son Joaquin pump Co. <br /> SIGNED TITLED-V-S;on e4 - <br /> D1tAW� PL 6T PLAN 'ON REVERSE SIDFl)l iq -' <br /> FOR DEPARTMENT USE ONLY Lana; California 9524D <br /> PHASE I �7 <br /> APPLICATION ACCEPTED BY 13 DATE <br /> ADDITIONAL COMMENTS: 14� <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE , <br /> E H 1426 Rev. 1-74 �� � , � <br /> 3/76 2M <br />