|
;.. SAN JOAQUIN EO.CAL HEALTH DISTRICT
<br /> FOR eOFFICE USE: 1601 E. Hazeltoft AveF,1 S:t6&ton, Calif.
<br /> Telephone:cl,"(2,'09) 46b;6;7.:81 ;
<br /> APPLICATION FOR 4LI: CONSTRUCTION OR PUMP PERMIT Permit No.
<br /> THISnPERMIT.#EXP:IRES I,FYEAR PRt3M=DATE;_ISSUED %S s Date-Issuedham(
<br /> Applic -�� �;R=c�(Complete;o-ln�Tr;ig.li-cate)=.�.��.�a °:.'
<br /> and/ora,Enstall.,the,workahereinde io tdes crib ed, ,This app3�cat 'on is. made,rtain: cop a ct
<br /> uin =Local Hea1th,D strict.:for ;a e"rmit-::to cohatru
<br /> ,e F � '" mpllance with San,Joaquin
<br /> County Ordi ►ance No..y$186Z;;anc3 the>,Rules-pand=Re,gmx-otions e.ofc,thei San';Joaquin t.ocali Bealih-.aDistrict.
<br />` �l5"Z�oN � ��� ,�O ,p R-�� •� 65'3 I o
<br /> JOB ADDRESS[LOCATION Ery�7 ya7r�
<br /> .+a- . SUS:rL L�ilV.4 x 5!�-..'a rAa,�ri
<br /> +�„�•;,Cr�� �,.a
<br /> Owner s N ` Z -
<br /> Phone-
<br /> Address,'
<br /> hone.Address.' 4e. _
<br /> ity"°
<br /> Con tractor's N&me.
<br /> { license on Z?
<br /> TYPE OF.-WORK
<br /> i (Ca1hkzt. .f .NEWWELY � - � /_DEPEN RECND3TION / TRU '
<br /> PPRIN$TLLATiONL7/ NP
<br /> 5 "
<br /> �
<br /> /. PUMP REPAIR "/ / PUMP REPLACEMEN
<br /> OtheT
<br /> r / / _ .. ,.. .. .
<br /> DISTANCE .TO NEAREST: '.S
<br /> EPTIC TANK ,
<br /> SEWER-LINES!
<br /> ; SEWAG$ DISPOSAL FIELD: p
<br /> PIT PRIVY
<br /> PROPERTY-.!L•INE PRIVATE 7DOMESTICSWELI,/S E ^ pUB =
<br /> z E GE PIT: OfiHER
<br /> LIC 'DOMESTIC :;TELL
<br /> 'INTENDED USE' = = FTYP$ OF WELD
<br /> CONSTRUCTION .SPECIFICATIONS
<br /> Iriclustria s f l�ab`le Took y. D „
<br /> tic/ r , a tof We1S1 Excavation
<br /> UDomes p �.vate .. Drilled s. Dia. P
<br /> of .Wel.l Casing
<br /> i Dompestic u
<br /> A blic' ,,Driven � � d p� I
<br /> S /+ SiI'!g
<br /> Gault of Ca • , �
<br /> Irrigation _ ; :Gravel' Pack h rout: Seal
<br /> Dept of G
<br /> CaGHodic .P" otecft -° =Rotary Type.`of :Grout
<br /> Disposal s Other Other Information:
<br /> Geo ti ,
<br /> ! p ysica� ' Surface Seal Installed By
<br /> •+
<br /> u
<br /> € Contractor t
<br /> -0 , .
<br /> PUMP INSfiALLATION. �
<br /> = Tipe `of Pump H.. .. ;
<br /> PUMP REPLACEMENT: ' / / ;S tate Work Dome' J.
<br /> �,.
<br /> PUMP 'REPAIR: / ]" °State Mork Done y. i.
<br /> y
<br /> tES�TRUCTION OF WEI ,L• - .. .... .. .. . € . . ., .
<br /> Well ,Diamete�
<br /> a e
<br /> i
<br /> Approxim to Depth "
<br /> Describe Material; and',Procedure"' ';
<br /> I hereby agree to comply raith all Dawe and regulations of the San Joaquin Local health District
<br /> ant d, .the State of California ,pertaining tp or x6gulat,ing ae11" c6ns'trciction. Within FIFTEEN RAYS
<br /> after co letioa of work ron a, new well . I will :fur ish ,.the. .San'Joaquin Local -Realth District a
<br /> WEST, I3ItII.LEgS REPORT of Che well and notify!them befoice putting. tlie. well id.use.. � The above 4
<br /> information is Crue to-.the-..best' of my'knvwledge"an`d-`b#liiaf.` I.wIIL. .CALL .FOR,Aj'-r;J'r INSPECTION
<br /> PRIOR TO GRfl ! IN D 1A FINAL INS E N ° A
<br /> SIGNED
<br /> $ TITLE i
<br /> ` :. DRAW'PLOT 'PLAN'ON REVERSE SIDE
<br /> PHASE .I. .. {_ { �,. .. ... FOIL-DEPARTMENT USE! ONLY
<br /> } #
<br /> APPLICATION ACCEPTED*BY _.. i S.. . , i " `i -.6—
<br /> . �
<br /> ADDITIONAL COMMENTS : DATE"
<br /> ;�PHAiGROUT INSPECTION t + PHASE II NAL INSPECTI N
<br /> INSPECTION BY DATE ° ' ? r
<br /> < INSPECTION 'BY DATE / #
<br /> <
<br /> �t E H 1426 � Rev. ].-74 -,
<br /> 1-7✓1 )M �
<br />
|