Laserfiche WebLink
" JOAQUIN LOCAL HEALTH DISTRICrA <br /> FOF OFFICE USE: 16(p. E. Hazelton Ave. , Stockton, Ca1�, . <br /> Telephone:. (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,j,5--,3? <br /> THIS PERMIT EXPIRES 'I YEAR FROM DATE ISSUED Date IssuedL�� <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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of ,the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner r s Name lov /��/ �,�f?C��lG _ _-- -- m Phone zo <br /> Address CG l l CatJ City - <br /> Contractor's Name Son Joaquin Pump Co. License Phone���--�Zl <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT 1�� <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY 01; <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 Grave] Pack— Depth of Grout Seal. <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. , <br /> PUMP REPLACEMENT: /State Work Done <br /> PUMP .REPAIR: / / State Work Done <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 wel.l "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 /> WELL DRILLERS REPORT of the well and notify them before putting the. wel.l in use.. The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> i PRIOR TO GROUTING AND AL SPECT 0 San Joaquin PUMP CQ. <br /> SIGNED TITLE <br /> (D LOT PLAN ON REVERSE SIDE): <br /> FOR DEPARTMENT USE ONLY Lodi, California 9 240 <br /> PHASE I a���� <br /> APPLICATION ACCEPTED BY DATVn <br /> ADDITIONAL COMMENTS: <br /> i PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY �' /��i _ DATE - <br />