Laserfiche WebLink
I <br /> OF SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOI �OFFxCE USE.- 1601 E. Hazelton Ave.; Stockton, Calif. e J <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, <br /> THIS PERMIT EXPIRES--1 YEAR FROM*DATE'I$S1io Date' Issued 7 a?7G <br /> (Complete In Triplicate) dbQ-as0-d3 <br /> Application is -hereby made to the San Joaquin Local Health`Di:strict �for d permit to construct <br /> and/or install the work herein described. This application' 19'm,ade in'comoliance with;San Joaquin <br /> County rdinauce�No. 1062 -and the Rules and Regulations of the San -.i"o"uia Local Health District. <br /> JOB ADD $$ '�£:2� 'JFla.zr.Y SiaE oF' L•3c`.ErY �� .�%%�.,s.�. _. . <br /> /LOCAT10 ,ys r o ec 7'aw6 .qv rCENSUS' T <br /> a1 RACT <br /> Owner's: Name u <br /> Phone ' <br /> Address1909, l p s3 <br /> Ct ty.SF/1�6/e Se-t��4 JCJ <br /> Contractor's Name San Joaquin Pump Co. <br /> License 37 Phone <br /> - <br /> �{ <br /> TYPE OF Lodi, Colifarnio 95 40 - <br /> 'WORK (Check)' NEW WELL L7 DEEPEN-J-7 RECONDITION /-7 DESTRUCTION /7y PUMP INSTALLATION -L-7 PUMP .REPAIR REPLACEMENT 17E{ • Other / 7 . . . . . .. . <br /> DI5TANCS TO NEAREST: SEPTIC TANK SEWER LINES _ '� <br /> S�1AGE DISPOSAL FIELD - PIT PRIVX _ <br /> PROPERTY LINE -- PRIVAT$ DOMESTICS�/SEEPAPUBiP,IC �STICTWELL'+�� � . <br /> YNTSNDEI} Ung TYpE iF WELL CONSTRUCTION SPECIFICATIONS Rti <br /> Industrial `� Cable Tool Dia. of Well Excavation <br /> Domestic/private ` Drilled Dia. of Well Casing <br /> Domestic/public Driven <br /> Irrigation Gravel Pack Gauge of Casing <br /> Cathodic Protection nota Depth of Grout- seal . <br /> -Disposal � Type of Grout <br /> ,__�� Other Other Information <br /> Geophysical Surface Seal, Installed 'B : <br /> PUMP INSTALLATION' Contractor <br /> Type of Pump <br /> PUBP REPLAN; ' •L/ State Work Done <br /> PUMP-!REPAIR; - Mate Work Done <br /> DESTRUCTION OF WELL: . Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> I hereby;.agree to comply with all laws and regulations of the 151:1111:1"30 in Local Health District <br /> And the State of California pertaining to or regulating well"construction. Within FIFTEEN DAYS <br /> after co6gletion of mp 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'GROtlT INSPECTION <br /> PRIOR TO GROUTTNG AND A 1�INAL INSP ION, <br /> SIGNED I TITLE Fan Joaquin Pump Co. <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I DEPARTMENT USE.ONLY Lodi, California 95240 <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COBS' DATE , -1�0 <br /> PHASE II GROUT INSPECTION <br /> INSPECTION SY DA2S PHASE I FINAL INSPECTI s <br /> INSPECTION BX DATE o <br /> E H 1416 Rev: 1:.74 <br />