Laserfiche WebLink
SAN JOAQUIN LOCA1, 1"JiIALTH. DISTRICT <br /> FOR OFFICE USE: 1.601 E. Calif. <br /> Telephone: '(209)-,4(0'-,,0`781 <br /> APR IUKATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. _7 7 6 <br /> THIS PERMIT,-EXPIRES 1, YEkR_,F1 OM .DATE '-ISSUED, Date Issued CK -7 -7 L_ <br /> {Complete In- Triplicate) <br /> - <br /> Application -is hdreby,made.-,to i the;.SanJoaqui-n,,Ladal Health District {f6r­a permit to construct <br /> and/or install the work herein described. Joaquin <br /> This-application made in compliance with San <br /> County-Ordinance :No.',,-1862:.and ,thd Rul:esl--arid'-Regulations ,of,".the .San. 'Joaquin Local-Health District. <br /> 'CENSUS TRACT <br /> JOB ADDRESS/LOCATIONQLD <br /> v V� 496 <br /> ' <br /> Owner�s,Name Rhone <br /> V <br /> City <br /> Address I — .. , <br /> !_7 <br /> License i Phone ' <br /> Contractor's Name <br /> DEEPEN ON /7 <br /> TYPE OF WORK (Check) : NEW WELL /7/ 7 RECONDITION DESTRUCTION <br /> PUMP INSTALLATION '/ PUMP REPAIR PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC .TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL .FIELD' . CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well. Excavation <br /> Dia. of Well Casing <br /> Domestic/private Drilled <br /> Domestic/public Driven; Gauge of Casing <br /> Z <br /> Irrigation Gravel Pack Depth. of Grout Seal 7J <br /> Other xF Rotary Type of Grout <br /> A Other Other- Information <br /> li <br /> PUMP INSTALLATION: Contractor <br /> Type of PumpH.P. N <br /> PUNJ? REPLACEMENT., State Work Done <br /> PUMP REPAIR: J 7 State Work Done <br /> " <br /> ,PESTRUCTION OF WELL. Well Diameter Approximate Depth <br /> Describe Material and Proceduie- <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 /> afte'i 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 put'ting. 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) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMEN S: <br /> MEN S' P- HAWjK:FTW INSPECTION <br /> Ii7R ECTION <br /> P. ��_L)i- OUT_1NSP <br /> _,6ROUT ' / DI <br /> BY <br /> INSPECTION BY I DATE INSPECTION <br /> SP <br /> CALL FOR 6, SPE6TION PRIOR.TO GROUTING AND FINAL INS <br /> 4/72 1M <br /> E if 1426 j <br />