Laserfiche WebLink
- i <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: YLICTHIS <br /> 601 E. Hazelton Ave. , Stocktori, Calif. <br /> Telephone: (209) 466--6781 9 <br /> ATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued s <br /> (Complete in. Triplicate) <br /> Applicationfis :hereby made to the San Joaquin :Local Health District for a permit to construct <br /> and/or install the work herein described. Thi's application is made in compliance with San Joaquin <br /> County Ordinance. No, l$62 .and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION (� fdnl CENSUS TRACT <br /> -jig ame <br /> At JW *- i►M Phone ' ' <br /> Owner's Name ^3' <br /> Address _ City <br /> Contractor's NameL <br /> _ �l�� ..c�Fiy �1" License # Phone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/ / RECONDITION /_7 DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP. REPLACEMENT /7 <br /> Other <br /> i < <br /> DISTANCE TO NEAREST: SEPTIC TANK - SEWER LINES " PIT PRIVY I <br /> SEWAGE-DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER-• <br /> F INTENDED USE _ TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 00 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public' Driven Gauge of Casing — � <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> F. � Other Other Information <br /> i <br /> PUMP INSTALLATION: Contractor _ . . —•---- �1 <br /> Type of Pump A � H.P. <br /> r . <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / State Work Done , p <br /> .DESTRUCTION OF WELL: Well Diameter - Approximate Depth <br /> Describe Material and ProcedureA, <br /> I hereby agree to comply with all laws yand regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS t <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 to the best of my knowledge and belief. <br /> SIGNED TITLE [ <br /> (DRAW PLOT PLAN ON REVERSE SIDE) r <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY W 'co, �LQ�I ci`�( DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE Il GROUT INSPECTION PHAS III/FIN INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A_ GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />