Laserfiche WebLink
56�Nl OAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. Stockto; <br /> Calif. <br /> Telephone: {209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.-72_-/ o Z 7 4 <br /> THIS PERMIT EXPIRES 1-YEAR FROM DATE, ISSUED Date Issued <br /> (Complete In Triplicate) O <br /> 7Z�-Y?mos' <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 compliance with San JoaquintF <br /> County Ordinance No.�186.2_and,,the,.-Ruies, and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT' <br /> Owner's. Name Gy A2 k1i .: Phone } <br /> Address <br /> - . �.; T City TOS _ 3 <br /> Contractor's Name �`�,�, _}��' j' � _ , x License # � Phone . <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION /7 DESTRUCTION /_ <br /> PUMP INSTALLATION '/ / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVYj'4 <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE <br /> 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 of Casing <br /> Irrigation - Gravel Pack Depth of Grout Seal i '` <br /> Other "' Rotary Type',of Grout / <br /> Other Other Information ' <br /> .PUMP INSTALLATION: ; "' Contkactor,, j,/� /,� �� <br /> Type of Pump U H.P. 9 <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR:` / / State Work Done f <br /> :DESTRUCTION--OF WELL: Well Diameter �7 _ _ >Approximate Depth -- <br /> Describe Material and Procedure ,4 <br /> I hereby agree to comply with all laws and regulations of the_San,Joaquin Local Health District <br /> ,and the State of California'wperta ping to or regulating well construction. ' WitIin.. EIFTEEN,DAY'S_ <br /> after completion of my work`on a new well, I will furnish the San Joaquin .L66a1 Health District a'"`? <br /> WELL DRILLERS REPORT of the well and notify them before putting the,,well_ in use•: The above <br /> information is tru to the best of my knowledge and belief. <br /> y�. ,�.. <br /> SIGNED i t ' �3 leTITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDID <br /> .PHASE I <br /> FOR DEPARTMENT USE ONLY , <br /> APPLICATION ACCEPTED BY � . DATE <br /> ADDITIONAL COMMENTS: x. use <br /> PHASE IIOU�TINSPECTION P SE-III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTI . t <br /> . .E H 1426 4/72 1M . <br />