Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH D' ISTRICIV <br /> FZUR OFFICE USE: 1601 E. Hazelton Ave. , StOCkto ., Calif. <br /> Telephone: (209) 466-6781- <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7,�- 3 5 0 <br /> q `f70 � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �(-L 8- 7 L <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 /> Co Hance . 186 and the Rules and Re uI tions of the San Joaquin Local Health District. <br /> if�G �s�•• S��,, c -itch c <br /> JDB DRE10 <br /> SS/LOCATION $— - (� CENSUS TRACT J <br /> Owner's Name jyO /� �z jy c- Phone S^; <br /> Address /Y C 'e%2 e!; City <br /> Contractor's Name f�L�a�G�, fi; License #;t4' ,Co Phone 444 9$39 <br /> fA Z ?off <br /> TYPE OF WORK (Check) : NEW WELTI / DEEPEN /_/ RECONDITION /_-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other / / — — <br /> DISTANCE TO NEAREST: SEPTIC TANK f7 Si SEWER LINES PIT PRIVY �- <br /> SEWAGE DISPOSAL FIELD 0.0 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 <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal Q <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> V1 <br /> PUMP INSTALLATION: Contractor ,c <br /> Type of Pump H.P. _! <br /> PUMP REPLACEMENT: / / State Work Done 60 <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 to the best of my knowledge and belief. <br /> SIGNED f, r-t u TITLE <br /> -(DEM PLO PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY Ca/ DATE 44 <br /> ADDITIONAL CO NTS• / ;H <br /> S GROUT INSPE ON T / AL INSPECTION <br /> INSPECTION BY DATE — INSPEC N B DATE <br /> CALL FORA ROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E x 1426 4/72 1M <br />