Laserfiche WebLink
w SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOTOFFICE 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 'EX,PIRES 1 YEAR.FRQk DATE:ISSUED Date Issued /�7 <br /> (Complete In'Triplicate). } <br /> Application is hereby 7made to the San Joaquin Local -Health District:.for,.a permit to construct <br /> and/or install the work herein described. This applicat�.on­ii tnmde in comp.liance.with San Joaquin <br /> County Ordinance .No. 1862 and the Rules and Regulations of the'Sai .-Joaquin:;Local 'Health `District. <br /> ,lac�tUE Fi+J V I C 7viz d [C e Hk"ua v � i <br /> JOB ADDRESS/LOCATION �f -v .CENSUS1TRACT <br /> Owner's Name ,, LiJ S L/4"e oR „�,.,,. e-c. . r Phone7- ,/ CJ <br /> Address / <br /> Contractor's Name has Joaquin Pump Co. License ,#3L1637ffPhone26t:v.L.:�. <br /> (Division ofon joaquj <br /> LL�� g ��p <br /> TYPE OF WORK (Check): NEW WE 7'_7 �Wfl0 "/7 RECONDITION DESTRUCTION f7,t PUMP INSTALLATION/ / PUMP REPAIR /er UMP REPLACEMENT <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 <br /> Irrigation Gravel Pack Depth of Grout Seal, <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information ' <br /> Geophysical �'� Surface Seal Ixistalled By: ' <br /> PUMP INSTALLATION: Contractor <br /> Type, -of Pum H.P. '. <br /> PUMP REPLACEMENT: . %/ State Work Done <br /> PUMP ;REPAIR: /l.f�"State Work Done .v l' Vk - <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"construct ion. 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 ,gqKING 'AND,ANDA FINAL INS CTION. son Joaquin Pump.Co. <br /> SIGNED µ TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I L.sadi, Califwnia 95240 <br /> APPLICATION' ACCEPTED BY l DATE <br /> ADDITIONAL COMMENTS: <br /> PHASEJI GROUT 'INSPECTTON PHASE 141 FINAL INSPI ON <br /> 4_INSPECTION BY DATE INSPECTION BY DATE ' <br /> �xi 1G9F ve : 1_7A f ' ' 1.h7ff 03M <br />