Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hdzelton:,-.Ave.`5-.;,Stockt:on, Calif. <br /> Telephone':;.. (209),',7466--=6781 <br /> APPLICATION FOR WELL CONStRUCTIONt-OR PUMP PERMIT Permit No. <br /> THIS PERMIT j,,EXP IRE S,<,1 YEAR viFROM(DAT E f-ji 5 SUED c i <br /> -(Cbmpl6tEi Iii Tripl <br /> e <br /> Appl"icatiloii,,)i:gLh-dreby�made;'�,,to theo4-aa:,J6aquiniLodal 14dalth) Distftd.t_!f6 m 0 <br /> r_ -a-�z �.pej '1 t,��t' ,,c-dristrj(jtt- <br /> and/or install the work herein described. Thidkapbldkcat F;made."ift.c:compliatce awith San-11oaquin <br /> County L:,0rdinafice cfXo v. l862,1arid,?t-herRu�;ffgaii'lt -di-Re --.Pons-�j6f`6the�s - - J6aquih:..,Lo6al;4_,Hjjjjt -'District., <br /> gulat an <br /> f` 2 0 <br /> JOB ADDRESS/LOCATION 17263 S. Brennan, EscalonCENSUS LTRA <br /> Owner.s c-Nimd0.T6,te-,r_yXis seml:.I I-',W C; -o­•I. <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER: El <br /> nono rTKIC <br /> Cqntrador's LicaMiS <br /> Contractor's Name I. J. Larsen Pumps: Inc License v ne 529-2020 <br /> TYPE OF WORK (Check) : ' NEW WELL DEEPEN '/ J RECONDITION /_/ DESTRUCTION /_7 <br /> 7 -7 <br /> PU -INS A�LLATIOI\l �/:'f':'-PUMP- REPAIR X-1UMP REPLACEME N <br /> T-- <br /> P <br /> DISTANCE TO .NEAREST:'*'SEPTIC,TANK\: ­ .SEWER LINES <br /> PIT PRIVY <br /> SEWAGE DI SPOSAL1.,-FI ELD'�,. CESSPOOL/SEEPAGE PIT . OTHER <br /> INTENDED USE -TYPE OF WELL ' CONSTRUCTION9SPECIFICATIONS <br /> i Industrial .Cable Tool aDia. of Well .Excavation <br /> I Domestic/privAte' Drilled <br /> Dia. of Well Casing <br /> Dome,sti-d/public Driven Gauge of.' Casing <br /> Irrigation.. ..Gravel Packk Depth; Grout ut.Seal <br /> Other Rotary Type of Grout <br /> Other Other'Information­,, <br /> J1 <br /> PUMP INSTALLATION: C6ntri6t6r <br /> ' Type of Pump H'..P. it <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: Pull pump replace <br /> State Work Done injector, pipe. . <br /> ;DESTRUCTION OF WELL: Well Diamet6r <br /> Approximate Depth <br /> 11-escri e Material -add7-Prbcedure <br /> I hereby agree to comply with all laws and regulations of <br /> the San Joaquin Local Health District <br /> and the State-'.'of'-Calif orfti ! ' <br /> a-pertainin-g to or regulating well construction. Within FIFTEEN DAYS <br /> .1 4 <br /> aftetr completion' of-;my'worl� on a new well, I will furnish the San 'Jo ' h District a <br /> f aquin Local Health <br /> WELL DRILLERS REPORT 0, them before putting the well in use. The -above <br /> f th� well and notify <br /> info'rmation is true: to: the lbest :of :my knowledge, and belief. % : jC <br /> IV BAN <br /> SIGNED <br /> TITLE , <br /> (DRAW PLOT PLAN ON REVERSE 'SIDE) <br /> FOR DEPARTMENT USE 0 LY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS; <br /> PHASE II GROUT INSPECTIONA <br /> JI tF I NAL INSPECTION <br /> INSPECTION BY DATE <br /> INSPECTION BX;;?��� PATE 7- <br /> dALL FOR A GROU <br /> • 7�.:"IN'INSPECTION _PRIOR <br /> RIOR TO G.RQqTING AND FINAL <br /> E H 4/72 IM <br />