Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR pF 'ICE USE: 1601 E. Hazelton Ave. <br /> ------_ Stac}rtara, 'Calif. <br /> Telephone: (209):,.466=b781 <br /> APPLICATION FOR WELL CONSTRUCTION,`.OR PUMP PERMIT Permit No. p�2 . <br /> --- <br /> THIS PERMIT .EXPIRES° l YEAR FROM..DATE 'ISSUED..- <br /> (Comple- te In TriPlicate) Date Issued 1p��d-7-L <br /> and/or <br /> is hereby iLiade -to the San Joaquin-Local ijealth District=for i permit -to construct <br /> and/or install the work herein described. This application is made.,in compliance `¢with San Joaquin <br /> County Ordinance No.� <br /> 1862 and .the Rules and Re u ations',of San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ]� s . �. d <br /> Owner's <br /> CENSUS'-TRA CTc r S <br /> Name: <br /> hone <br /> Address <br /> City w <br /> Contractor's Name ` �J <br /> License ����'l(Lp <br /> hone 5t <br /> TYPE OF WORK (Check); NEW WELL; / DEEPEN • <br /> _/ / RECONDITION / DESTRUCTION <br /> PUMP INS _ /AL ATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> E <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES PIT PRIVY `� <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> 11 INTENDED COTENDED USE �I� TYPE OF WELL OTHER <br /> Industrial NSTRUCTIONSPECIFICATIONS <br /> I Gable Tool .Dia. of <br /> Domestic/private Drilled Well Excavation -� <br /> Domestic/public Dia• of Well Casing <br /> Driven Gauge of Casing <br /> Irrigation Gravel. Pack <br /> Other Depth of Grout Seal <br /> Rotary Type of Grout <br /> IM Other Other Information ' —t � <br /> AntractorT- <br /> PUMP INSTALLATION: <br /> Type of Pump <br /> 1M H.P. <br /> PUMP REPLACEMENT: /I�/ State Work Done <br /> PUMP REPAIR: /11I11 State Work Done <br /> pESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <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 wank 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. <br />:SIGNED ; <br /> TITLE <br /> �j (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APP ICATION ACCEPTED BY - <br /> ADDITIONAL COMMENTS: ,gyp DATE _ V _ v <br /> PHASE II GROUT INSPECTION PHASE III/FAINL NSPTION <br /> IEC <br /> INSPECTION BY PHASE INSPECTION BY LD' • <br /> . CALL FOR A GROUT INSPECTION PRIOR TO. GROUTING AND FINAL INSPECTION. DATE -yam <br /> EH1426v _ <br /> 4/72 -1M <br />