Laserfiche WebLink
4 <br /> SAN JOAQUIN LOCAL..HEALTH DISTRICT <br /> FOF OFF?ICE USE: 1601 E. Hazelton Ave. ,,�Sto kton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2 <br /> THIS PERMIT EXPIRES 'l YEAR FROM DATE ISSUED Date Issued <br /> ' .'(Complete In Triplicate) 2_6 �(— Z3o -L j <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct' <br /> F <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County ,Ordinance 'No. 1862 ana the Rules and .Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �Q" Qn CENSUS TRACT <br /> Owner's Name P i } - FZ e r frc Phone <br /> i <br /> Address 12 City 'T-a r \I <br /> Contractor's Name ` l' License # r9qogPhone 526 - <br /> 4 <br /> TYPE OF WORK='(Check)---'--NEW'WELi:/_7'.: '_DEEPEN`/_/ --REC"ONDITION""/_/"DESTRUCTION /__ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other --- k <br /> DISTANCE TO NEAREST: SEPTIC TANK — SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE. -- PRIVATE DOMESTIC WELL Z2 PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation " <br /> Domestic/private k Drilled Dia. of Well Casing {D <br /> Domestic/public DrivenGauge of Casing &0 <br /> Irrigation i Gravel -Pack. Depth of Grout Seal <br /> Cathodic Protection _ Rotary "" "¢ Type'of' Grout' <br /> ` Disposal Other Other Information SI 4 ��r <br /> r Geophysical Surface Seal Installed B <br /> f <br /> IPUMP INSTALLATION: Contractor <br /> Type sof Pump -H.P. <br /> PUMP REPLACEMENT: Y/% State Work Done Y <br /> PUMP REPAIR: / / State Work.'Done - _---� .; • _ _ <br /> DES-TRUCTION OF WELL: Wellr',Diameter Approximate Depth <br /> SI <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 ''c6 struction. 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. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. = TITLE ,1jQlr, "�� <br /> SIGNED s S <br /> I (DRAW PL(3T PLAN ON REVERSE SIDE) <br /> FOR WARTMENT USE ;ONLY <br /> PHASE I i ���r�``� 1 " ���� <br /> APPLICATION ACCEPTED BY DATE h=-�_ _ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/Fl AL INSPECTION <br /> INSPECTION BY DATE =—_7 Z INSPECTION BY DATE <br /> 1�j7 <br /> E H 1426 Rev. 1-74 : <br />