Laserfiche WebLink
_=01 <br /> SAN JOAQUIN LOCAL Ut ALTTJ 'DISTRICT <br /> FO1.601 E. Hazelton Ave. , Stockto:t, Calif. <br /> Telephone : (209) �'66-6781 <br /> 4 - - <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Til <br /> THIS PERMIT EXPIRES 1 YEAR ]SROM DATE ISSUED Date Issued /� 71 <br /> (Complete In Triplicate) <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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local. Health District. <br /> JOB ADDRESS/LOCATION iG 1c CENSUS TRACT <br /> Owner's Name -- Phone <br /> Address t <br /> �U � .�� L, U' � City <br /> i <br /> Contractor's Name t�ti� -c License #l/ Phone- <br /> TYPE OF WORK (Check) : NEW WELL /�/ DEEPEN /�/ RECONDITION /7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other /_J t� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD-) CF,SSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> U-- Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> v Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump tt H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> .DESTRUCTION 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 well and notify them before putting the well in use. The above <br /> information is true the best of my knowledge and belief. <br /> SIGNED TITLES 1 -ci <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> DATE <br /> ADDITIONAL COMMENTS: -- i <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> i <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />