Laserfiche WebLink
r J ' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOt ;OFri'ICE USE: 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) 466-67811 <br /> 1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � . <br /> THIS PERMITEXPIRES l YEAR FROM DATE:ISSUED.,_ Date Issued ' <br /> (Complete In Triplicate) ,, " s; F <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 applicati-oin is- �sade-'.in compliance:with San Jaaquiri:' <br /> County Ordinance No. 1862 .and the Rules and Regulations of the -Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION. . SEC R EVERS6 Fn2. L[s��T1U cENsus'TRACT <br /> Owner's Name .. atca Lt <br /> Phone . <br /> Address.: / 41 P�2�.r '"� �a�q 4 City L o:Q. <br /> Contractor's, Name Son soaquin Pump Co. , <br /> V r go. License # 3ID:;378Phone ] - <br /> � <br /> Lodi, California 9524 <br /> TYPE OF WORK (Check): NEW WELL/? DEEPEN/7 RECONDITION f-J DESTRUCTION /7 <br /> PUMP INSTALLATION UMP REPAIR/_7 PUMP REPLACEMENT f7 <br /> F <br /> Other <br /> DISTANCE TO NEAREST: - SEPTIC TANK SEWER LINES PIT PRXVY. -*.�' <br /> ,.SEWAGE DISPOSAL FIELD _ CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRI MESTIC WELL:' _ - _P-UBLIC DOMESTIC-•WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION�SFECIFICATIONS <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 /> i�Cathodic: Protection Rotary t_ TS►pe of Grout <br /> O Dis oral '0'1 }. .. <br /> P > 1 Other _ O.ther-Info' rmation, <br /> Geophysical All Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor cr.sc� <br /> Type >of Pum <br /> p <br /> PUMP REPLACEMENT: ' State Work Done ' <br /> PUMP .REPAIR: # <br /> / 1 State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> 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 'o€ 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 GROUTING AND A FINAL INSPECTIO <br /> SIGNED ..— TITLE San Joaquin Pump Co. <br /> (DRAW PLOT PLAN ON REVERSE SIDE -, <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY !Lodi, Califort:i�a 95. <br /> APP � � . . <br /> LICATION ACCEPTED BY <br /> . - DATE .2y 2 <br /> ADDITIONAL COMMENTS: i ""_ <br /> PHASE II GROUT INSPECTION PHASE I INSPECTION <br /> INSPECTION BY DATE INSPECTION BY E - 2—7- <br /> 'E"H 142.6 Rev. 1-74 <br /> ti.iry� <br />