Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH-DISTRICT <br /> FCFE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76- J��P <br /> THISIPERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 9 -7{7L <br /> .I (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herei" 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 /> JOB ADDRESS/LOCATION 17215 Lawrence CENSUS TRACT <br /> Owner's Name P. Blackmore Phone <br /> Address same City <br /> Contractor's Name I. J. Lars n Pumps , Inc . License # 276660 Phone 529-2020 <br /> i' <br /> f <br /> TYPE'OF WORK--(Check):: NEW WELI�-/'"/ DEEPEN'/ / •RECONDITION/"/ "DESTRUCTION / =S - - <br /> PUMP INSTALLATION/ / PUMP REPAIR / / PUMP REPLACEMENT /� <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 . t <br /> Industrial I Cable Tool Dia. of Well Excavation \ <br /> Domestic/private Drilled bia. of Well Casing r <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection i Rotary Type of Grout <br /> Disposal t Other Other Information ' <br /> Geophysical Surface Seal Installed BY: ; <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT:/ State Work Done 'Pull old jet', ' install 1 hn subm.-Pipe_• _ <br /> PUMP .REPAI-R: f / State Work Done <br /> DES-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> r <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 t9 the best of my knowledge and belief. I WILL CALL,,FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AN4/_A RUALI)j8`P,ECTiON. - <br />,SIGNED TITLE '. <br /> ` bRAW Ph T PLAN�'ON RE FRSE SIDE *-�-- ` <br /> FOR DEPARTMENT USE .ONLY 5 <br /> PHASE I <br /> APPLICATION ACCEPTED BY � J _ DATE <br /> ADDITIONAL COMMENTS: t <br /> PHASE II,g UT INSPECTION ;' PHAS' /TINAL- INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 3/76 2M. <br />