Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FQ 'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 75-4.;U,/o <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> .(Complete In Triplicate) <br /> Application is hereb)Pinade co the San Joaquin Local health District for a permit to construct <br /> anti/or install the work herein described. This application is made in compliance with San Joaquin <br /> ' County Ordinance No. 1862 and the Rules and egu1 tion& oft an Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION � O � l/c � CENSUS TRACT <br /> t Owner's Name t7 2 0' I-IAAWLEL Phone Z 3e/ ., .. <br /> j Address - O/F Cl_uZ Zzleyif City.' wr ,086?I A C., <br /> Contractor's Name -Son .looqu°rre Pump Co. License # . Phone,, <br /> } 4 e+........ ...wa.3A...�-'�.•WOf V111-366quin Sulphurc&j -- - l <br /> M <br /> Lodi California/4F4% <br /> TYPE OF WORK (Check); Nbi WELL EEPEN -/7 RECONDITION /7 <,DESTRUCTION /_]r <br /> PUMP INSTALLATION /� PUMP REPAIR /_7.PUMP REPI:ACEMENT <br /> Other I 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE » PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELT, ,. <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 /> j 'Domestic/public Driven Gauge of Casing <br /> E Irrigation = Gravel, Pack Depth of Grout Seal <br /> Cathoiiic P'r_e tecfion.__4____ Rotary- - - - Type of--Grout- <br /> Disposal <br /> f,-Grout Disposal. Other Other Information 's <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type,of Pump H.P. <br /> PUMP REPLACEMENT: • , State Work Done S L_144 <br /> -��-..�.t'r <br /> 'PUMPT-.REPAIRi�-`� .. /' I State Work'Done <br /> IDE&TRUCTION 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 /> Fend 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 /> WELL DRILLERS REPORT of- the well- and notify them before putting-the.-well. in.use.. The above <br /> , WELL <br /> is true to the-best-of- my knowledge and belief. I WILL CALL FOR A ,GROUT INSPECTION <br /> JPRIOR TO GROUTING AND A VINAL INSP CTION. Safi loaquin Pump Co. <br /> SIGNED TITLE Division of Son Joaquin Sulphur Co.) <br /> (DRAW PLOT PLAN ON REVERSE SIDE) '_700 C- Kertleman <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY '� _ DATE , JP//f TJ <br /> ADDITIONAL COMMENTS: <br /> PHASE' IIJGROUT INSPECTION PHASE III FINAL INSPECTION <br /> p <br /> INSPECTION BY DATE INSPECTION BY % DATE +- <br /> E H 1426 Rpv. 7-74 �� <br />