Laserfiche WebLink
F M <br /> Wu SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR.'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 i <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. a- ,-79bo <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> p I (Complete In Triplicate) Dom_ /.f0 -0y <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 /> %4F a.0 /1! yGpti.4 +is SDu of KF /Frha Ga�� Wes r`s i of o F <br /> JOB ADDRESS/LOCATI[ON i:_ S ;Y; .i V:4a t q 8 a a T 7S os CENSUS TRACT <br /> Owner's Name PhoneV'- 91136 <br /> Address I Z. City <br /> San Joaquin Pump Co, <br /> Contractor's Name (p; ; nn n( SnF S3� <br /> License ;� Phone. I <br /> 711 N. Satramento St. <br /> - .� - .•--• - Lodi, Caiifa•rnia 95240 <br /> TYPE OF WORK (Check).: NEW WELL /? DEEPEN / RECONDITION /-7 ' DESTRUCTION /-7 <br /> PUMP INST TION / PUMP REPAIR / / PUMP REPLACEMENT /-7Other / 4 3 J <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY . <br /> SEWAGE IDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER 1 <br /> f� <br /> f INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool-I ' Dia. of Well Excavation i <br /> Domestic/private' ' F Drilled x Dia.' of Well Casing <br /> Domestic/public ► Driven --.Gauge-of Casing .. _ _.. <br /> Irrigation g Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor S/�� .3 u i} (,t l �0 9[.e«'I P C'U CrU D f <br /> Type of Pum <br /> yp r p / H.P. <br /> 2 C� <br /> 4 ft{�mC�'� �✓�r�.SGr�i�/ �L�/l1� l2f .P�.�'✓.ST�L,C <br /> PUMP REPLACEMENT: / / State Work Done i i[JCic�, "ev <br /> PUMP REPAIR: / / State Work Done <br /> ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply withlall 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 /> So, Joaquin Pum- Co. <br /> SIGNED ^� (Division of Sin Joaquin Sulpyur cu.) <br /> �..c' TITLE c.,.- m,, <br /> (DRAW PLOT PLAN ON REVERSE SIDE Ing; r„i•r <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED.BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INS ECTION PRA&E III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BYDATE - �L <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION r <br /> E H 1426 �' 7/72 IM <br />