Laserfiche WebLink
r <br /> FOR OFFICE USE. SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. , Stockton, Calif. r <br /> Telephone: (209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> p Date Issued 7� <br /> Application is hereby made t10 the San Joaquin Lo al Healthete In District -�7c _ <br /> District for a <br /> and/or install, the work herein describedn <br /> .. Thi$ a permit to construct <br /> County Ordinance No. .1862 and the Rules and Regulations tofthe Sans madeJoaquinpLocal eHealthwithSJoaquin <br /> District. <br /> � 'u lUPST Slu est- 4-t-4 mccjSC �(3Cr.Th1 SfUc� t+f ict <br /> JOB ADDRESS/LOCATION tocU1.)6r, 6ev R p � e,FF Tine-riv u ��,�� S o�, �-M 1� <br /> r p �r,K or c�i e� CENSUS TRACT Ol? -(oo-z.0 <br /> � G. �r .tire <br /> Owner's Name <br /> 1 Phone <br /> Address 17 -0 A-) �,� <br /> (. � <br /> Contractor's Name Sar: Joaquin Pump Co. City 1:) f <br /> License # Phone 304<171 <br /> J r <br /> TTP O WORK ­(Check): NEWCWELL �� U <br /> DEEPEN /-7 RECONDITION /_/ DESTRUCTION /- <br /> PUMP INSTALLATION / / PUMPS REPAIR <br /> Other /W/ PUMP REPLACEMENT /? <br /> /% �." <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL, FIELD CESSPOOL/SEEPAGE PTT <br /> OTHER <br /> INTENDED USE TYPE OF WELL <br /> IndustrialCONSTRUCTION SPECIFICATIONS <br /> 1 Cable Tool Dia, of Well Excavation <br /> Domestic/private I/Public _ Drilled <br /> Domestic Dia. ,of Well Casing <br />�-�-= . <br /> _ <br /> Irrigation. - + - :Gauge-..of_.Casin ter . - +- <br /> . , 1" Gravel .Pack Depth of Grout Seal Y <br /> Other f Rotary Type of Grout <br /> I Other Other Information <br /> PUMP INSTALLATION- Contractor <br /> Type of- Pump <br /> PUMP REPLACEMENT: State Work Done <br /> r <br /> PUMP REPAIR: State Work Done <br /> .. .. Tun <br /> RESTRUCTION OF WELL: Well Diameter <br /> 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 /> TELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> Lnformation is true to the best of my knowledge and belief. <br /> iIGNED s San Joaquin Pump Co. <br /> Y � TITLE (Division of San Joaquin Sulphur Co.) <br /> {DRAW PLOT PLAN ON REVERSE SIDE <br />'RASE I I FOR DEPARTMENT USE ONLY <br /> PPL CI ATION ACCEPTED By <br /> DDDITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTION INSPECTION <br /> NSPECTION BPHASE III F NAL Y DATE INSPECTION BY _ <br /> CALL FOR A GROUT INSPECTION .PRIOR TO GROUTING AND FINAL <br /> E H 1426INSPECTION. DATE ' <br /> • <br /> 7172 Im <br />