Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT F <br /> FOF OFCE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> �`� Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.�� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued e J7 <br /> (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 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 /> JOE ADDRESS/LOCATION ��y r+.rl� ,Jorz�iNyr l�oc> tz�1�G� Rd CENSUS TRACT <br /> Phone <br /> Owner's Name •u Ie Q e. <br /> City Lon r � <br /> Address a ju . Cls R r �� / <br /> License �� Phone, 7� <br /> Contractor's Name san.Joaquin Pump Co. xx <br /> (Division of San Joaquin &flphar Co.) <br /> TYPE OF WORK (Check) : N&d4aV79WbEN / / RECONDITION /-7 DESTRUCTION /? <br /> PUMP INSTALLATION // PUMP REPAIR PUMP REPLACEMENT / <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 4 CESSPOOL/SEEPAGE PIT OTHER. <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> * -CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE TYPE OF WELL <br /> Industrial Cable Tool Dia. of'Well Excavation <br /> Domestic/private <br /> Drilled <br /> Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> NI <br /> Irrigation .. . �F, _t. Gravel Pack Depth of Grout Seal <br /> Rotary _ v Type o <br /> Cathodic Protection .. Grout <br /> y <br /> Disposal Other Other Information ' A <br /> Geophysical Surface Seal Installed By:._ <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type of Pump - {� <br /> PUMP REPLACEMENT / / State Work Done r <br /> PUMP- .REPAIR: ., _ /Z7�.State: Work Done [� �u tK�l l N p �'t�l �IQ�S�7P� <br /> Gnu►`{- <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter r <br /> i 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 /> s after completion of my work on a new :well, I'wi.11. 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 /> C 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 INSPE <br /> SIGNED .� TITLE fan boa gain Pum _ <br /> 7mlnMWL T PL ON RE ERSE SIpEXDivision nF 5an�coquin 5u1 h'ur Co <br /> FOR DEPARTMENT USE ONLY at. <br /> Lodi, Cafifornfcrnia ia 95 9540 <br /> I PHASE IDATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE III/FINAL INSPECTION <br /> PHASE II GROUT INSPECTION INSPECTION BY DATE / `.77 <br /> INSPECTION BY DATE <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 <br />