Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFi,OFFICE USE: v 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.. ZL-a-y-2p <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE `ISSUED Date Issued -76 <br /> (Complete In Triplicate) OlJ�_ pip O3 <br /> Application is hereby made to the San Joaquin Local Health District For a permit to construct <br /> and/or install the work herein described. This application is made' in compliance with San Joaquin <br /> County 'brdinance No. 1862 and' the Rules and Regulations of the San Joagt:in Local ..Health District. <br /> [•R€,erg- .ec,Ao --.2 fi•/es EF►s <br /> JOB ADDRESS/LOCATION OF ncw L04.,5- -- 7r i CENSUS TRACT <br /> Owner r s I Name Phone <br /> Address4- 7- X /Q_y City.��,U <br /> Contractor's Name Sort Joaquin pump Co, License phone c 7� <br /> ,rs,on or an Joaquin Sulphur Co,) <br /> TYPE OF WORK (Check).. W&wei r;iEEPEN '/-7 RECONDITION /-7 DESTRUCTION /-7 M <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 <br /> Industrial <br /> Gable Tool Dia. of Well Excavation � <br /> Domestic/private Drilled Dia. of Well 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 Information <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / I <br /> /v� State Work Done <br /> PUMP 'REPAIR: / / State Work Done . <br /> Y v 5 <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 coinpletion 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 belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO'GROUTING AND A FINAL INSPECT N. <br /> SIGNED �- TITLE San Joaquin Pump Co. <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Lodi, Ca{ifarnia 95240 <br /> APPLICATION' ACCEPTED BY DATE - -73� --]j <br /> ADDITIONAL COMMENTS: <br /> PHASE 11 GROUT INSPECTION PHASE III FINAL, INSPECTI N <br /> INSPECTION BY DATE INSPECTION BY � ^- DATE !o <br /> E S 1426 Rev. 1-74 h/75 2M <br />