Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT � <br /> F_OFFICE" U5L 1601 E. Hazelton Ave. , Stocktpm, Calif. � <br /> Telephone: (209) 466-67$1 : <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.,7fl- - <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued�,2_ <br /> (Complete In Triplicate) <br /> Application is hereby spade to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein escribed. - This ap lication-is ma ompliance with San Joaquini <br /> County Ordinance No. 862 an u s nd.,L"�j a in Local: Ieal,th District, <br /> JOB ADDRESS/LOCATION 37 SUS TRACT ' <br /> Owner's NamePhone - <br /> Address e City <br /> A <br /> Contractor's Name cense hone <br /> f. <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN '/ / RECONDITION /_/ DESTRUCTION J� <br /> PUMP INST LAT ION / / PUMP REPAIR / / PUMP REPLACEMENT /� <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing l <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout 25 Z <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br />-;—'PUMP REPLACEMENT:REPLACEMENT { / State Work Done <br /> PUMP 'tEPAIR: / / State Work Done <br /> ,DFGTRUCTION 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 regulating 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 we and notify thein before putting the well in use. The above <br /> information s true to the b t € my knowledge and belief. <br /> SIGNED TITLE <br /> (DV PLOT PLAN ON REVERSE SiD <br /> FOR DEPARTMENT USE ONLY <br />• FHAS I <br /> APPLICATION ACCEPTED .BY DATE S� <br /> f ADDITIONAL COMMENTS: - IM 670 <br /> PHASE II aOUT INSPECTI PHASE I I/FINAL INSPECTION <br /> INSPECTION BY DATE 17 INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR T GROUTING AND FINAL INSPECTION. <br /> r. .r -i I of r, /7g1M ' <br />