Laserfiche WebLink
�,r�w,�gbFj, / � by <:y..r •�� ' _ - � ?t�., - <br /> i _ s trs- <br /> inz <br /> cl <br /> ti r � SAH JOAQUIN LOCAL -HEALTH-bISTRICT S17�} -3 1 r <br /> ` sFOb OF:'ICE ' Hazelton Ave.. _StacktaA` Calff ^ <br /> ..s. r Ac�•13 b.rrF. �•:4-Kw ,+F. uS. r• jy _ ;_ <br /> one <br /> tAPPLIGATI Telep �.;{204}.:-466 .67$1; '�`�s�cF�akx a=� �rrr,�n-.�.,'�.ck�`��I>,� t '�•.1 <br /> aw- ter: ' ��, a t�N FOR WELL CONSTRUCTION OR PUMP PERMI rw <br /> .�. -PERMIT"", Pei'>oait Ho ] �,•s a <br /> - <br /> rw ..+ y�'�Yt;i* S¢,n.a.� e y+�y"a1 Y:`w�'`�,'rA^ .a <br /> y' <br /> THIS PERI��T`EI�IRES 1`'YEAR Wag <br /> FROM DATE°xSSUED5 4 ��Y <br /> o-k s Y {Complete In Triplicate) � 4.3yL�• <br /> Applica�ion 3s�h y' made to the Safi;Joaquin:.Local,Health:Distiict�fora;permit.to;- strue <br /> v �.�. <br /> as /or iastall the �rork <.�erein described s"appliaatinn "is made=in compli`encs with .San'�oaquia <br /> r 'County'Ordinance No: 1862 and the'Rules aad Regulations of the San' Toaquin;Local Healt}i;Die"trict`.' <br /> n dot C. y ;- <br /> ' � JOB ADDRESS/LOCATIONS f `" •t` s i``^ 1 <br /> S »CENSUS <br /> Ow[ier's-Name. f Lowes 7�iri�:`k'd ;.z? 'z ` 3 7 <br /> £ Phoneir <br /> r rs <br /> f r,,,..✓ '. - <br /> yy� tContractor's Name License Phane S <br /> ` } TYPE ti�F <br /> WO Check) NEW WELL-,-L7',DEEPEN / RECONDITION /7 . DESTRUCTION.17 <br /> F S <br /> s, <br /> PUMP INSTALLATION / UMP REPAIR'/� 'PUMP REPLACEMENT: / <br /> � <br /> 1 j <br /> r,.� _ as � ...'• :, :_ : •- - -- <br /> u �N EDISTANCE TO NEAREST: SEPTIC TANK 450 -SEWER LINES PIT-,PRIVY <br /> SEWAGE.DISPOS MELD CESSPOOL/SEEPAGE PIT <br /> OTHER <br /> a r PROPERTY LINI PRIVATE DOMESTIC WELL E � PUBLIC DOMESTIC WELL I <br /> � ^s . INTENDED USE TYPE OF WELT. CONSTRUCTION SPECIFICATIONS, <br /> - cf } Industrial Cable Tool Dia,' cf'Well'Excavation '1� �� �' ;.:°s� W k <br /> / •• Domestic/private Drilled Dia. of Well Casing <br /> a•a Domestic/public Driven Gauge of Casing`: <br /> s i <br /> � t� irrigation - - Gravel Pack. Depth .of Grout Seal - <br /> '7 Cathodi' rotection Rotary Type of GrouC <br /> s <br /> Disposal Other Other Information ► <br /> } ,s Geophysical SttLf aGP_-Se8��R3t�xicxr-v �► i <br /> PUMP INSTALLATION Contractor �r � �• ,f t' <br /> ' <br /> . <br /> u r, t Type of. Pump H.P. <br /> PUMP REPLACEMENT State Work Done <br /> gee-PUMP .REPAIR / % State Work Done 6 1 <br /> DESTRUCTION OF WELL: Wel] ;Diameter Approximate Depth <br /> Describe Material and Procedure 3°= I <br /> I hereby agree-to comply with all laws and regulations of the San Joaquin Local Health Di'strictr,�, <br /> x <br /> he,.State,of California pertaining to or regulating well'con3truction. Within FIFTEEN DAYS-,­ <br /> after <br /> AYS-after completion of my.work on a new well, I will furnishthe San Joaquin Local Health Di'strict'a <br /> 4: <br /> WELL DRILLERS'REPORT of the well and notify them before putting the well in use. The above w: <br /> information is true to the best f my knowledge and belief, I WILL CALL FOR A GROUT INSPECTION;:•,._;; <br /> "PRIOR TI AND PF):kATION. <br /> SIGNED / TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> a PHASE I <br /> ' APPLICATION ACCEPTED.BY. ,,! , ,"'� DATEZ2) <br /> A-DDITIONAL COMMENTS: - <br /> , PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> Et <br /> INSPECTION BY DATE INSPECTION BY DATES'• A� <br /> E H 1426 Rev. 1-74 1177. 7 <br />