Laserfiche WebLink
IL-.01la c / SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOL O. FICE USE: !/ 1601 E. Hazelton Ave. , -n, Calif. <br /> Telephone: (209)466-6781 <br /> tea-°tip APPLICATION FOR WELL-CONSTRUCTION OR PUMP PERMIT PezmitNo, p <br /> j 77„L4/p. i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 1- <br /> (Complete In Triplicate) ± <br /> Application is hereby. made to the San Joaquin :Loca1 Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and` the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION - •'CENSU'S TRACT , <br /> Owner's Name rr <br /> Phone <br /> r [ <br /> Address A.� City ` S f <br /> Contractor's Name License #4A71- e _ � 7474 ' <br /> is <br /> t .E <br /> TYPE OF WORK (Check) : NEW WELL/7 DEEPEN% /• RECONDITION /% DESTRUCTION /7 <br /> h <br /> .PUMP INSTALLATION '/ / PUMP REPAIR '/!/ PUMP REPLACEMENT /-7 <br /> Other <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 (��1 <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 of Casing <br /> Irrigation i Gravel Pack Depth. of_ Grout Seal <br /> Cathodic Protection b .,Ro.tary-.R Type° of Grout <br /> Disposal Other Other Information ' <br /> Geophysical _ Surface Seal Installed By: ' <br /> PUMP INSTALLATION: Contra ILr - <br /> Type-' of Pump G - H.P. <br /> PUMP REPLACEMENT: F/ . <br /> / / .State Work Done <br /> PUMP .REPAIR: 'State Work Done1 <br /> , �/ .. <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree 'to, comply wi-th. all laws and regulations of the SaneJoaq�in Local Health District t <br /> and the State,-of California pertaining to or regulating well 'construction. 'Within FIFTEEN .DAYS <br /> afteri,c6tgple'tion of my work on a new well, I will furnish the San J_aaquin 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 TO GROUTING AND A FINAL I SOIETWO # <br /> SIGNED . TITLE � �'• ! <br /> RAW ' PLAN ON TERSE SIDE f: <br /> FOR D FARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: ; <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 77 I <br /> E H 1426 Rev. 1--74 3/76 2M ; <br />