Laserfiche WebLink
(� SAN JOAQUIN LOCAL'MEALTHy'DISTRICT <br /> FORMFICE USE: 1601 E. Hazelton`Ave.°; '.Sfbi: t6ii, Calif. <br /> / <br /> Telephone: --(209)`_466:-6781:`,. <br /> 7AP LICATION FOR WELL'CONST}}RUCTIOTN OR PUMP PERMIT Permit No. <br /> ///////// THIS PERMIT EXPIRES. I,YEAR :FROM-'DATE .ISSUED Date Issued ll-,,Y- <br /> Complete <br /> l- - 7.G <br /> • _ (Complete�,1n-,Trip lcate) <br /> Application is hereby made to the San Joaquin Local.,Jlealth.3District for a permit to construct <br /> and/or,install the work. hereiii described. _w,This ,:application.1s..made in compliance with San Joaquin <br /> County Ordinance No.. _1862 and the Rules and.,Regulatfons);of,:the -San •Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION +.�64�'•, . r.. d ` CENSUS TRACT <br /> ...... <br /> Owner's Name Phone <br /> Addresst" rF`3 6��' . :.. L - -.,.,� _ City p <br /> Contractor's.:Name , License #,E� �v� Phone. X31.3 <br /> - - f <br /> TYPE: OF WORK,-(Check): NEW WELL /�-. DEEPEN:-/? RECONDITION /? DESTRUCTION /_7 <br /> PUMP INSTALLATION. RUMP REPAIR PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PTT PRIVY <br /> SEWAGE 'DISPOSAL ESL'/ <br /> FIELD CSPOOSEEPAGE PIT OTHER <br /> PROPERTT LINE -- PRIVATEDOMESTIC WELL 'PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia;- of Well. Casing - ' <br /> Domestic/public Driven Gauge,o'f Casing <br /> Irrigation Gravel Pack Depth of; Grout Seal <br /> Cathodic Protection Rotary ."Typeof Grout <br /> Disposal Other. R Other-Information <br /> Geophysical _ Surface Seal Installed BY: <br /> PUMP .INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done l <br /> PUMP :REPAIR: /� State Work Done <br /> ,SES-TRUCTI_ON_ 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 is true to the-best of my .knowledge •and-belief. 'I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TOG 99UTING AND A FINAL INSPECTION. �.,._. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN -ON REVERSE SIDE) <br /> „ FOR DEPARTMENT •USE ONLY <br /> PHASE I /j <br /> APPLICATION ACCEPTED BY DATE -_ e "' / D <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I FIN INSPECTION <br /> I'I INSPECTION BY DATE INSPECTION B 'aAa DATE / <br /> 4 E H 1426 Rev, 1=74 1-74 2M <br />