Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR 6FFI.CF USE: 1601 E. Hazelton Ave.-, Stockton, Calif. <br /> Telephones (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No: <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued <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 compliance with San Joaquit <br /> ' County Ordinance No. 1862 and the Rules and Regulationswof the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> G <br /> Owner's Name ,� �. �S' %�,� J.tJ Phone <br /> t Address e z City . '1—o o / <br /> Son Joaquir. Pump Co. <br /> Contractor's Name (Division of 5an Joaquin Sulphur Co.) License # Phone <br /> f 711 N. Sacramento 5t. <br /> ` TYPE OF WORK (Check): NEW WELL / / DEEPEN / / RECONDITION /_7 DESTRUCTION /TT <br /> PUMP INSTALLATION / / PUMP REPAIR :/!.{ -PUMP REPLACEMENT /7 <br /> Other /_7 F`', — <br /> T <br /> h <br /> DISTANCE TO NEAREST: SEPTIC.TANK SEWER-LINES PIT PRIVY <br /> --SEWAGE`-DI'SPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> t <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> I Domestic/private Drilled Dia. of Well Casing \ <br /> Domestic/public Driven `Gauge of Casing <br /> Irrigation Gravel Pack ' Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> i <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: /L•/-' State Work Done -J C7 G x) d C g4&kle <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> l <br /> r I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State -of' <br /> tate 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 /> j 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. <br /> Sorg Joaquin Punip Co. <br /> SIGNED TITLE (Division of San Joaquin Sulphur Co, <br /> (DRAW PLOT PLAN ON REVERSE SIDE !C I N. Sacrartiento St. <br /> r <br /> FOR DEPARTMENT USE ONLY Laar, Lahtornra 95240 <br /> PHASE I DATE �=�-f" <br /> APPLICATION ACCEPTED BY c" d2 2 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FI AL INSPECTION/ <br /> E INSPECTION BY DATE INSPECTION BY ggx.aDATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />