Laserfiche WebLink
x u)3 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR"*OF ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No: Z,/1- /3.,L< <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued LZI 7b <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 Joaquii <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health Distract. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name I4,V I/ q ,U U T ,,L) Phone <br /> Address 117fr� Lu lu 2�uo'/2 CitC <br /> . r- y <br /> Contractor's Name 'San Joaquin Pump Co. , <br /> Of c, h F: License # Phone <br /> Lodi, Cal fiornio 95240 <br /> TYPE OF WORK (Check) : NEW WELL /7 DEEPEN /_7 RECONDITION /_7 DESTRUCTION /`7 <br /> PUMP INSTALLATION / / PUMP REPAIR. ./ / PUMP REPLACEMENT / <br /> Other /_7 <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 /> f Domestic/private yr Drilled Dia. of Well Casing <br /> Domestic/public Dr.i_v_enGauge_.of.-Casing <br /> Irrigation Gravel Pack _ Depth of Grout Seal <br /> - Other Rotary Type of Grout <br /> Other Other Information <br /> 1 <br /> PUMP_ INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> tP------ PLACEMENT: /tate Work Donee 215%L L 72i e-&rte �C-#v <br /> i <br /> PUMP REPAIR: / / State Work Done <br /> .s - — <br /> W <br /> CTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> l 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 /> itiformafton is true to the best of my knowledge and belief. <br /> ----- San Joaquin Pump Co. <br /> SIGNED a 1 TITLE <br /> (Divi ion of San Joaquin SuE h <br /> (DRAW PLOT PLAN ON REVERSE SIDE) 711 N. Sacramento St <br /> PHASE I FOR DEPARTMENT USE ONLY Lodi, CalifQrnia. 95240 <br /> APPLICATION ACCEPTED BY DATE 3 � <br /> .:ADDITIONAL COMMENTS: <br /> j PHASE II GROUT INSPEC ON P FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />