Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOH OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. 1 �"� r <br /> Telephone: (204) 466--6781 / 2 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT `Perrot No. � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ./2,­/­3-77 <br /> 7 Q� • ,c�.a�aEU �� (Complete In Triplicate) ��-3-- 0,9-03 Lr <br /> Application is hereby made to the San Joaquin Local -Health District for a permit o 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 /> J�DRESS/OCATION EG ¢� - <br /> �� aF t� ,�'.c,�'Y C_x)ZZ_ZA enil-.� _ CENSUS TRACT - <br /> Owner's Name `® ,J _,�2g <br /> / Phone 31 7— z��. <br /> Address ell72e (5-. City �U� <br /> Joan Pump Co. - - - <br /> Contractor's Name (Division of Son Joaquin Sulphur Ca License # J�6??R Phone �l <br /> acramento St. <br /> nlp yp � <br /> TYPE OF WORK (Check) : NEW 14ELL / / DEEPEN /_/ RECONDITION /_/ DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR /— IP REPLACEMENT /_7 <br /> Other <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 WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation Q S <br /> Domestic/private Drilled Dia, of Wel]_ Casing , <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout. Seal <br /> Cathodic Protection Rotary Type of Grout <br /> ]Disposal Other Other Information1� <br /> Geophysical. Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> a <br /> PUMP .REPAIR: /L. 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 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 /> information is true to the best of my knowledge and be .ief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING NAL �N ECT <br /> SIGNEDTITLE San Joaquin Pump CO. - <br /> �(Division e4Sen jeaetu:�Sa rhup Qj <br /> (TDMOLOT PLAN ON REVERSE SIDE) ,. Z. <br /> PHASE I FOR DEPARTMENT USE ONLY Logi, Ca(ifara-La 95240 <br /> APPLICATION ACCEPTED BY �1 DATE Z r1 j <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION IV PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY zo DATE 3-2c, 7;� <br /> E H 1426 Rev. • 1-74 %%7 _ 2M <br />