Laserfiche WebLink
c� <br /> � � Sp' TOAQUIN LOCAL HEALTH DISTRICT s <br /> 1601 a: Hazelton Ave. , Stockton, <br /> os <br /> OFFICE <br /> USE: Telephone: (209) 466-6781 PERMIT permit No. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP Date Issued 6 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In Triplicate) tom <br /> permit to construct <br /> lication is made in compliance with San Joaquin <br /> described. This app <br /> plication is hereby made to the San Joaquin Local Health Dis <br /> rict or a <br /> Id/or install the work herein <br /> ,unty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> l <br /> CENSUS TRACT <br /> )B ADDRESS/LOCATIONS ^ --C_ 356 / <br /> Phone 7 5 / - <br /> mer's Name 412 _ City <br /> dress E) r <br /> Phone <br /> )ntractor's Name ion Joa uin Pump i oe <br /> License # 16 --�-- <br /> (Division of San jcaga Sulpha+ to.) <br /> `1 fr?F 9 pE QRECONDITIONS/ DESTRUCTION 1-7 <br /> INSTALLATION REPAIR / <br /> L-f PUMPMEPLACEMENT <br /> PUMP INST /7 <br /> 'PE OF WORK (Check) : NBV <br /> Other <br /> [STANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> PIT PRIVY \ <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER V <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL— PUBLIC DOMESTIC WELL -- <br /> INTENDED USE TYPE OF WELL CONSTON RUCTISPECIFICATIONS <br /> _ Industrial Cable Tool Dia. of Well Excavation <br /> _ Domestic/private Drilled Dia. of Well Casing <br /> _ Domestic/public Driven Gauge of Casing Q1 <br /> _ Irrigation Gravel Pack Depth of Grout Seal <br /> _ Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> UMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> UMP REPLACEMENT: / / State Work Done + _1 <br /> 'UMP '.REPAIR: /{`State Work Done e1dj (2n (un�nl 7-O '30p T� � <br /> ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> .nd the State of California pertaining to or regulating well 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 /> TELL 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 /> RIOR TO GROUTING AND A FINAL INSP5EION. <br /> SIGNED �_ i1 _�- TITLE San Joaquin Pump Co. <br /> (DRAW PLOT PLAN ON REVERSE SIDE)i Division of San Joaquin u p�ur <br /> FOR DEPARTMENT USE ONLY ry <br /> Lodi, California 95240 <br /> PHASE I <br /> APPLICATION ACCEPTED BY C r DATE �- i- rf <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTI N 7/ <br /> INSPECTION BY DATE INSPECTION BY DATE /0 /d <br /> E H 1426 un„_ 1-74 <br /> 4/75 2M <br />