Laserfiche WebLink
?AXUJOAQUI �OCALHEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave.,;t Stocktor., Calif. � E <br /> Telephone:, ! <265) .466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION'.,.OR PUMP PERMIT Permit No._7?_ 3 6 <br /> s <br /> THIS PERMIT 'EXPIRES, l YEAR'FROM DATE i ISSUED- Date Issued .S -7---7 Z_-a- <br /> (Comple'te In Triplicate) <br /> Application,is..hereby.madeTto the,San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is •made incompliance with San Joaquin <br /> County-Ordinance No.,41862 and., the.--Rules=and' Regulations of,1the- 'San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 7jCENSUS ZRACT" <br /> Owner!s. Name" t Phone <br /> Address <br /> city C <br /> - - - <br /> _ <br /> Contractor's Name aG/ ie License # Phone # <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/—/ RECONDITION /_/ DESTRUCTION <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT <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 /> i ' <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia: of Well Casing RC1 <br /> Domestic/public Driven Gauge of Casing , <br /> Irrigation Gravel Pack Depth of Grout Seal .. <br /> Other Rotary Type of Grout <br /> Other Other Information ' <br /> PUMP INSTALLATION: Contractor, <br /> ' Type._of-Pump' i H.P. <br /> PUMP REPLACEMENT: / / State Work Done <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 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 ' true to the best of nowledge and belief. <br /> SIGNED TITLE <br /> _00 W P T PLAN ON REVERSE SIDE) ` <br /> DEPARTMENT USE ONLY <br /> PHASE I "�- � <br /> APPLICATION ACCEPTED BY j <br /> ADDITIONAL COMMENTS: <br /> ' 4 PHASE II G PHAS <br /> ,. / N SFECTION <br /> INSPECTION BY TE INSPECTION BY / DATErq, <br /> ' ,Z2 .E <br /> CALL FOR A GROUT. IN ECTION_PRIOR TO GROUTING AND FINAL INS IQ <br /> E H 1426 4/72 1M <br />