Laserfiche WebLink
SAN JOAQUIN LOCAL:'HEAL'T'H`tISTRICT <br /> FOFi OFFICE USE: 1601 E. Hazelton Ave,.," ES<to6kt6'ii, Calif, <br /> Telephone: .(209) _x W-67'81-;:ry;, 1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77/o/z <br /> THIS PERMIT EXFIRES° 1';,YEA—RnFROM_DATE ISSUED Date Issued ;2 Jp- <br /> f. r: (Complete °in Tr p3lasts) <br /> Application is hereby made to the San Joaquin,Lacal-Health, D.istr-Act for a permit to construct <br /> and/or install,the work herein. described. ,rThi.a application:,�s, made in compliance with San Joaquin . <br /> County Ordinance No. 1862 and he Rules Regulati s'! the ,San Joa uin Local Health District. <br /> JOB ADDRESS/LOCATION � � �ENSUS TRACT <br /> Owner s s Name <br /> /�' Phone. <br /> Address: I s- w . .._.m,... . .m_..._ ..:._ Cit - � <br /> y � <br /> Contractors Name ULicense # Phone�3 6r X 33 1 <br /> f <br /> I <br /> TYPE OF WORK (Check) : NEW WELLDEEPEN /? RECONDITION /7 DESTRUCTION f7 <br /> _, _PUMPV' INSTYATION / / PUMP REPAIR /-7 PUMP REPLACEMENT /7 n 1 <br /> 4 Other <br /> � 1 <br /> DISTANCE TO NEAREST.: 'SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT; OTHER € <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �I <br /> Industrial able Tool Dia. of Well Excavation r' <br /> _ Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation <br /> Gravel Pack Depth'of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal OtherOther'In-formation <br /> �� . . <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor . <br /> Type of Pump - ; , H.P. <br /> PUMP REPLACEMENT: / State Work Done ` <br /> PUMP ,REPAIR: —State-Work Done: . . . <br /> ES•TRUCTION 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 regulaCIng 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.-beet-of- my knowledge and belief. I WILL CALL FOR A 'GROUT INSPECTION <br /> PRIOR TO 9,MDUTING AND INAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR-DEPARTMENT USE ONLY + <br /> PHASE I <br /> APPLICATION ACCEPTED BY 1 DATE ` <br /> ADDITIONAL COMMENTS:, <br /> PHASE II GROUT INSPECTION PHASE I. /FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION- BY -DATE " -� <br /> t :E H 1426 Rev. 1-74 1_74 9M <br />