Laserfiche WebLink
" SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � ,�o <br /> _ THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 /> wrs f OF 4Jcc L -'AP­2G-e- o.,) t-jvvv8RbGe R.0 mbo" f- <br /> JOB ADDRESS/LOCATION 6&6 YbL& �n10ENSUS TRACT <br /> Owner's Name LO . Phone Az/ 6 /- Z$" <br /> Address 7 gq c.R2 City 40 [.Ta.S <br /> Contractor's Name San Joaquin Pump Co. P5�7 <br /> iariawn ul hur Co.) License # 31&-378 Phone <br /> - r mento St. <br /> Lodi, Ccslifarnia 957-40 <br /> TYPE OF WORK (Check) : NEW WELL /_7 DEEPEN /_7 RECONDITION /7 DESTRUCTION /`7 <br /> PUMP INSTALLATION /I.?PUMP REPAIR /—/ PUMP REPLACEMENT /7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <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 Gauge of Casing <br /> - <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor LO�e l l by &e6ss <br /> Type of Pump 2 a.,--ve H.P. 1� <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / 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. <br /> San Joaquin Pump Co. <br /> SIGNED TITLE (Division of San Joaquin Sulphur Co.) <br /> RAW PLOT PLAN ON REVERSE SIDE "• S.-mamn.tu <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE tf <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASg NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> L H 1426 7/72 1M <br />