Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> fO <br /> FOE FICE USE: Rly 1601 E. Hazelton Ave. , Stockton, Calif. <br /> ,. Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7�/nS3jo <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 8�t 77 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> nd/or install the work herein described. This application is made in compliance with San Joaquin <br /> iounty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> O:eras <br /> ADDRESS/LOCATION /4 r++ OE Jo2sh° Uo 1eJ000i3t rb�� fLd <br /> CENSUS TRACT <br /> Phone <br /> Name ` E .0 r E , <br /> City <br /> Fddress d ' Q l ). 0,9 R r 2b . / <br /> San.7oa uin Pump Co. License # . / Phone jp ��7/ <br /> Contractor's Name 9 " <br /> (Divialon of Son 9ogquin swphur ke _ _ - , <br /> TYPE OF WORK (Check): N d atsfa 9' PEN�— ;NDITION /-7 DESTRUCTION /— <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT /� <br /> ' Other %/ F <br /> DISTCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRI <br /> ANVY <br /> ' SEWAGE DISPOSAL FIELD i CESSPOOL/SEEPAGE PIT OTHER. <br /> PROPERTYLINE - PRIVATE DOMESTIC WELL — PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool -,Dia. of W11 Excavation <br /> Domestic/private Drilled '` Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing \l <br /> Irrigation �. _ Gravel Pack Depth of Grout Seal <br /> ' type of Grout <br /> Cathodic Protection - Rotary Other Information <br /> Disposal Other <br /> Geophysical <br /> Surface Seal Installed BV* <br /> ' PUMP INSTALLATION: Contractor H,p, <br /> Type of Pump <br /> ' PUMP REPLACEMENT: / / State Work Dane <br /> State: Work Done e ImKJ l 14 P' �'�r" r' 7 e <br /> PUMP_ .REPAIR: .. _ /!'1�. �7Ce?ue <br /> Approximate Depth <br /> ' DESTRUCTION OF WELL: Well Diameter <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'taill furnish the„San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify <br /> them before putting the .well in use. The above <br /> edge and belief. I WILL CALL FORA GROUT LNSPECTION <br /> information is true to the best of my knowl <br /> PRIOR TO GROUTING AND.A FINAL INSPE , TITLE 'San 30040” Pume Co' „ <br /> SIGNED Division of San'liouquln$u1 hur'Co) i. <br /> D W Pt T' PL ON RE EkSE ---- <br /> FOR DEPARTMENT USE ONLY Sacramento t. <br /> Lodi, California 95240 <br /> '.I PHASE DATE <br /> APPLICATION ACCEPTED BY 4 I <br /> j ADDITIONAL COPSESII GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> i INSPECTION BY <br /> INSPECTION Br/�� DATE / �P_� '� <br /> Y �_ DATE -- <br /> 3/75 2M <br /> E H 1426 Rev, '1-74 <br />