Laserfiche WebLink
SAN JOAQUIN LOCAL UEALTH DISTRICT <br /> FOR OFFICE USE: .- 1601 E. Hazelton Ave. , Srockton4 Calif <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL,-CONSTRUCTION OR PUMP PERMIT Permit No. 7 a- 6 0 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE'-ISSUED ; Date Issued 2, 1­­7A,,- <br /> (Complete <br /> , ­ 71Y(Complete In Triplicate) T f` <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 incompliance with San Joaquin <br /> County Ordinance No:',,`1862 aii the ' ul an egulati6ns of the San Joaquin Local Health District. is <br /> w A-3 f <br /> JOB ADDRESS/LOCATION cs'L ryN�' yL �CENSUS TRACT <br /> ctj- <br /> Owner's Name, 11/Al d o'- m. . s Phone 'i b�1 * a <br /> - - <br /> Address <br /> -d City. LD 1?f c-PF <br /> - c► i <br /> Contractor's Name License_41 s� / Phone y.��g _3q. <br /> TYPE OF WORK (Check) : NEW WELL/ J DEEPEN / /" RECONDITION /7 DESTRUCTION /_7 <br /> ' 'PUMP:,INSTALLATION PUMP REPAIR'/ PUMP REPLACEMENT /-7 <br /> other <br /> DISTANCE TO NEAREST: SEPTIC TANK 7 Si SEWER LINES - _ PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER f <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 0 i <br /> Industrial Cable Tool Dia. of Well Excavation <br /> _ Domestic/private Drilled Dia. of Well Casing Z j <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth, of Grout Seal <br /> Other Rotary - Type of Grout <br /> Other Other Information <br /> , <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / /` State Work' Done <br /> PUMP REPAIR: / / State Work Done <br /> ESQ TRUC'TION OF WELL:- Well Diameter Approximate Depth <br />( Describe Material and Procedure <br /> F I hereby agree to comply with all laws and regulations of the San Joaquin Local Health DistrictVr <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 furdish -the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the well se. The above <br /> information is true to the best of my knowledge and belief. _ <br /> SIGNED , a TITLE <br /> W PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY , <br /> PHASE I <br /> APPLICATION ACCEPTED BYDATE <br /> ADDITIONAL COMMENTS: <br /> PHASE IT GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE -7 2__ � <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />