Laserfiche WebLink
� - SAN JOAQUIN LOCAL HEALTH DISTRICT, , <br /> FOF OFFICE USE: 1601 E. Hazelton Ave, ;sSt;oc'_{ton; Calif. <br /> Telephone: (209) 466-6781 `7!/� <br /> ' APPLICATION FOR WELL CONSTRUCTION OR PUMP -PERMIT Permit No. 11`"``` <br /> f, 7 <br /> THIS PERMIT EXPIRES. l'OYEAR:.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 /> r and/or install the work herein described. This .application;lis made in compliance with. San Joaquii <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health .Di.strict. <br /> ,' JOB ADDRESS/LOCATION Z 7 S CENSUS ,TRACT " <br /> Owner's Name y^ Phone <br /> Address H� `�. 1 _ City - -� <br /> Contractor's Name ' icense j,Q Z/9$ Phone <br /> TYPE OF WORK (Check) : I�I,NEW WELL /DEEPEN RECONDITION /_/ DESTRUCTION <br /> AL <br /> ,PUMP INSTALLATION )ACJ _PUMP REPAIR ! / PUMP REPLACEMENT / f <br /> ' Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES =�� PTT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOLYSEEPAGE PIT OTHER (� <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL 1 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> �mestic/private' Drilled Dia. of Well Casing • <br /> F Domestic/public Driven Gauge ofCasing <br /> Irrigation Gravel Pack ., Depth o£! Grout Seal , "10 <br /> Cathodic Protection 4_---Rotaxy' Type of Grout �'. eye <br /> t Disposal Other Other Information n fb <br /> Geophysical Surface Seal Installed By: '0 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump "� ._ . H.P <br /> PUMP REPLACEMENT: / / State Work Done <br /> 4Ro--.� - >-. Tie.,. —"'-...r--. K—.�- .:-... ----.,..,�:.^^�---•=- - +.,,... -,.,,, _ -_ ., *,;i^..,._.,r- rr-,�•,r.-. <br /> ; PUMP .REPAIR: Mate Work Done - <br /> s / <br /> IDES-TRUCTION OF WELL: 'Well Diameter Approximate Depth <br /> Describe Material and Proc�du're�T � � - <br /> f V <br /> I hereby agree to comply with all lafs., and,, regular onslof the ;San Joaquin Local Health District <br /> and the State of California pertaining tb 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.I� I WILL CALL FOR A GROUT INSPECTION <br /> ► PRIOR TO GROU NG 4NP A FINAL INSPECTION. <br /> SIGNED �' I�TITLE <br /> ][ (DRAW PLOT PLAN ON REVERSE SIDE) - <br /> I� FOR DEPARTMENT -USES.ONLY, <br /> PHASE I _ <br /> APPLICATION ACCEPTED BYV`� <br /> DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE ,III/FINAL INSPECTION <br /> INSPECTION BY Aj II DATE — INSPECTION BY DATE <br /> .. E H 1426 -Rev. - l-7,4 //7 2m <br />