Laserfiche WebLink
' 3 . / SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> CE USE: {/ 1601 E. Hazelton Ave., Stockton, Calif. <br /> ' Telephone: (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES i YEAR FROM DATE ISSUED Date Issued s_ <br /> (Complete In Triplicate) <br /> on is hereby made to the"San Joaquin Local Health District for a permit to constt <br /> stall the work herein described. This application is made in compliance with San <br /> ' dinance No: 1862 and.lthe Rules and Regulations of the San Joaquin Local Health D3 <br /> AC.a+n o4co ln->4 W 2 fl .0c4t-Tf! o a its.vw�rJ <br /> SS/LOCATION yrs f.fi oP_ q-E £'_o.dZ CENSUS TRACT <br /> 1 �. <br /> am Pfl`q '�C !?��A,J4d Phone <br /> ' ,2/3 7 9 A), Jed City 14Ciq-rz�0 <br /> is -Name San Joaquin Pump Co. 9 <br /> ouq Oyu License /0`��� Phone _ <br /> ( -51ona <br /> ' -fil PgM-Fir^�T_sa <br /> CCaiifaraia 5^ <br /> )RK <br /> (Check) Lod': IEW WELL DEEPEN /% RECONDITION DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR /� PUMP REPLACEMENT /_7 <br /> Other 0 ✓ <br /> CO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> ' SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> ENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> istrial Cable Tool g Dia. of Well Excavation <br /> ' istic/private Drilled . Dia. of Well Casing <br /> :stic/public Driven Gauge of Casing <br /> Lgation Gravel Pack ;Depth of Grout Seal <br /> ' !r Rotary Type of Grout <br /> Other Other., Information.` <br /> ' LLLATION: Contractor <br /> Type of; Pump H.P. <br /> _e <br /> ' LCEMENT: /��/ State Work Done <br /> :R: x�jState Work DonePr <br /> J <br /> ' )N OF WELL: Well.'Diameter Approximate Depth <br /> Describe Material and Procedure <br /> ' agree to comply with-all laws and regulations of the San Joaquin Local Health Dis <br /> :ate of Calif ornia'pertaining to or regulating well construction. Within FIFTEEN <br /> iletion of my work oa a new well, I will furnish the San Joaquin Local Health Dis <br /> ' .ERS REPORT of the well and notify them before putting the well in use. The above <br /> m is true to the beat of my knowledge and belief. <br /> TITLE San Joaquin Pump Co. <br /> n of San Joaquin Sulphur Cs.) <br /> (DRAW PLOT PLAN ON REVERSE SIDE) 71� N. Sacramento St. <br /> �j FOR DEPARTMENT USE ONLY Lodi, Ca!ifarnio <br /> ' 1N ACCEPTED BY A,, DATE 44 " <br /> COMMENTS. d I 7 <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> ' BY DATE INSPECTION BY G DATE <br /> IR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> 6 7/72 1M <br />