Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 'FO ;'6FFI_ CE USE: 601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 75= SD3y� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued Ze-7 7� <br /> (Complete In Triplicate) ` <br /> Application ig' hereby made to the Sam Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This appUcation 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 /> -- Phone L_-r <br /> Owners Name .) ftp /_G��C' - <br /> Address / c) / 9 di!f/D �Q City Z_�4 0 l <br /> Son Joaquin Pump Co. Phone e- %7 <br /> Contractor's Name Wivision of.Son Joaquin Sulphur co.) ' License V <br /> 500 E. Kettleman <br /> a 1, a i o'rnia 95Mw. E :. <br /> TYPE OF WORK (Check): -- NEW WELL`/�j DEEPEN '/7 RECONDITION I_T DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other / 7 - <br /> 3 .. <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 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public - Driven Gauge­Lof Casing <br /> Irrigation �� -- Gravel Pack Depth of Grout Seal <br /> Rotary ; T e of Grout ' <br /> Cathodic Protection F YP <br /> Disposal Other Other Information, <br /> Geophysical Surface Seal Installed 'B <br /> PUMP INSTALLATION: Contractor <br /> Type. of Pump A.P. <br /> PUMP REPLACEMENT: State Work Done Le Q1n1 i OPAO AL AUZA-42 (d2 1/y/ .0eg46) <br /> y ' <br /> f-PUMP -:REPAIR`: --: _ /7-- -Done <br /> DESifRUCTION 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 PAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> IWELL 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 INSPECt ION <br /> PRIOR TO GROUTING AND A FINAL I PECTION.: San Joaquin P'ump.'Co. <br /> 'SIGNED TITLE (Division of San Joaquin Su <br /> DRAW PLOT PLAN ONREVERSE SIDE E. Kettieman <br /> FOR DEPARTMENT USE ONLY LOal, a I arnia 95240 <br /> PHASE I <br /> ' APPLICATION' ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II G OUT INSPECTION PHASE III FINALXng <br /> INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE f <br /> 79 u Z 1.9�, Dati, 7—7 G r <br />