Laserfiche WebLink
SAN JOAQUIN -LOCAL TIFALTT',. DISTRICT ' <br /> FOR OFFIUr USE: / 1601 E. Hazelton Ave. ;'•Stocktor-y Calif. <br /> f' Telephone {209} 4GG=6781 <br /> + Y APPLICATION FORAWELL CONSTRUCTION• OR PUYX PERMIT Permit No. <br /> 73 <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 with San'Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �'�� � / `�� So 15✓eES&,; Co CENSUS TRACT ' <br /> Owner's Name re- �r e C Phone 'a d c-) <br /> Address -- [� City <br /> Contractor's Name � �� / ,ZooK <br /> � Phone <br /> License ��� <br /> msTYPE OF- WORK (Check) :__ NEW WELL :KL , PEEPEN_'/_/ 1RECONDITION L DESTRUCTION-f?, <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 CP <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing . <br /> Doirtestic/public Driven Gauge of Casing /2 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout 14!!�Ag <br /> Other Other Information ' <br /> z <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump �Si�Ii � r /m - H.P. <br /> PUMP REPLACEMENT: / / State Work,Done <br /> PUMP REPAIR: / / State Work Done <br /> ,DESTRUCTION OF WELL: Well Di-a-me t­e-r 'F � App _roximate D--epfh <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 1 <br /> WELL DRILLERS REPO"f the well and notify them before putting the well in use. The above <br /> information is, tpde to the best of knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �1,6Ay <br /> APPLICATION DATE ACCEPTED BY �/4 _ _ _ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE //- p'X3 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 IM <br />