Laserfiche WebLink
JOAQUIN LOCAL HEALTH DISTRIe <br /> FOR OFFICE USE: 1 . . , , s , <br /> Calif. <br /> � Telephone: (209 466-6781 <br /> APPLICATION WELLCONSTRUCTION PERMITT Permit No. <br /> THIS IT IRS 1 DATE ISSUED Date Issuedd jZj <br /> (Completei <br /> Application <br /> mads: to the San Joaquin Local. Health District for a pelt to construct- <br /> and/or i .st 1.1 the work herein described. This application is made iu a lianc Vith San Joku <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Lech Health ft trict <br /> d S SS/ TIS .R Casus mcr <br /> Phi <br /> Address 7 city <br /> Contractor's Name <br /> (Check) , WELL L7 DEEPEN CONDITION - DESTRUCTION N <br /> P1W INSTALIATION PUMP REPAIR / PUW REPIACEMEWO <br /> DISTANCE TO NEAREST.- SIMC TAS SEWER LAE , PIT PRIG <br /> SEWAGE N?ISP PILE CLS-SPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE PRIVATiFDOMESTIC WELL P LIC TI <br /> INTENDED USE TYPE OF WELL CONSfRUdtION 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 Gravel Pack Depth of Grout Seal <br /> Cathodic Protection . X: � Rotary Type of Grout <br /> Disposal Other Other Information <br /> -GeophysicalSurface Seal Installed � <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUNP REPLACEMENT: / / Mata Work Done <br /> P' :REPAIR: 17 Mate Work Lane <br /> DE <br /> So" RU TI I t P WELL. Well Dia ter pt®�e mate th <br /> Describe -Material and Procedure <br /> I hereby agree, to comply w t i all laws and regulations the San Joaquin Leal alb isttict <br /> and the State of California pertaining to or re ul.atinS well -constru tip. I��thir �I DABS <br /> after co pl. tiAn work on a newwell, I will i` ish the Sau Jc a.qu �t'La�cal alth District <br /> WELL DRILLERS ERS PORT 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. 1 WILL CALL FOR A. GRIT INSPECTION <br /> TIt <br /> PRIOR Nl PIAS I'N CTION. <br /> g <br /> TITLL � ,�... <br /> RGNErDRAW PLOT-,--PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> PLICATION ACCEPTBY DATE <br /> S <br /> ADDITIONAL O ATS <br /> i <br /> PHASE II GROUT INSPECTION Pun II m MATE <br /> EINSPECTION R BATE INSPECTION <br /> r <br />