Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> r <br /> -;.OFFICE USE: ` 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6783 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. J,. M410 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued 2z _7s__ <br /> (Complete In Triplicate) <br /> Application is hereby trade to the San Joaquin-Local Health District far a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1-862and the Rules anal Regulations of the San Joaquin. Local Health District. <br /> 29 . <br /> JOB ADDRESS/LOCATION Fps-SA2 al oo n B R,Ea6F i?o n c�, c)(,i CENSUS TRACT 017- 330-0` <br /> Owner's Name %G, !cam M-) Phone <br /> Address <br /> CIT! ® City ' L <br /> Contractor's Name (Division of San Joaquin Sulphur co 1 <br /> License # Phone <br /> r <br /> TYPE OF WORK (Check): NEW WELL '/? DEEPEN '/ RECONDITION %f DESTRUCTION /-7 <br /> PUMP INSTALLATION /7—PUMP. REPAIR .-q PUMP REPLACEMEOF 17 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY _ <br /> - r SEWAGE DISPOSAL FIELD — CESSPOOL/SEEPAGE PIT F OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial <br /> Cable Tool Dia. of Well Excavation � <br /> Domestic/private Drilled Dia. of Well Casing 1 <br /> Domestic/public Driven Gauge of Casing ; <br /> Irrigation `�'" <br /> E Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other,'Information ' + <br /> Geophysical .. . <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor lb <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . / / State Work Done i <br /> i <br /> •,� <br /> PUMP .REPAIR: 7/`)t/7 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 belief. I WILL CALL FOR GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. ion .Y®ogttin tttttp o. <br /> SIGNED J — TITLE fpivision of son Joaquin suiphur Go.! <br /> (DRAW PLOT PLAN ON REVERSE SIDERettlemun <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY Lodi, <br /> ° 1 <br /> .... _ <br /> APPLICATION' ACCEPTED BY DATE ' 73 <br /> ADDITIONAL COMMENTS: <br /> PHASE II Gjt0UT INSPECTIO_ . PHASE II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 'E h 1426 RP-v. 1-74 <br />