Laserfiche WebLink
Cv SAN JOAQUIN LOCAL ,HEALTH DISTRICT <br /> 0—R.rOFF CE USE: 1601 E. Hazel tori'Ave Stackton, Calif. <br /> !� Telephone: <s1(209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR'PUMP PERMIT - Permit No. <br /> THIS -PERMIT EXPIRES 1 %YEAR•4FROM- DATE• ISSUED Date Issued _fit 1 <br /> ' (Complete..In,,Triplicate) <br /> Application is hereby made to the San Joaquin,Locnl-,Ilealth D sta:ict' Four a permit to construct � <br /> and/or install.ityhe,work herein described. This application, is made in compliance with San Joaquin! <br /> County Ordinance No: 1862. and the Rules and,Regulations of the San Joaquin Local Health District.: <br /> JOB ADDRESS/LO .. ION. CENSUS TRACT <br /> C <br /> Owner's Name I Phone <br /> Address'- Y _._. -... - <br /> ?_? L : city a <br /> Contractor's Name . .... License - k►hone y --7( ( <br /> 767 701 <br /> TYPE OF WORK <br /> (Check) : NEW WELL/? DEEPEN RECONDITION RECONDITION /? DESTRUCTION /7 <br /> PUMP INSTALLATION —PUMP REPAIR Z/ PUMP REPLACEMENT /7 <br /> Other /D7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER�LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVA DOMESTIC WELL' PUBLIC DOMESTIC WELL <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 DrivenGauge of Casing <br /> Irrigation Gravel Pack . Depth of Grout Seal <br /> Cathodic Protection Rotary. _ Type of Grout' <br /> Disposal �� . Other Other Information <br /> Geophysical Surface. Seal Installed 8 <br /> PUMP INSTALLATION: Contractor . <br /> Type of Pump H.P. w <br /> PUMP REPLACEMENT: <br /> - State Work Done <br /> PUMP ..REPAIR: State Work Done <br /> V <br /> ES;TRUCTION OF WELL: Well Diameter V Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Loca3 Health District <br /> and the State of, California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completiori� 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 txue to the-best of mytowl9oge. ,an belief. I WILL CALL FOR A GROUT INSPECTION I <br /> PRIOR TO GROUTING AND A FINAL INSPE N: I <br /> SIGNED TL ITLE 'Qa <br /> { LOT PLAN ON ERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> SE <br /> ACCEPTED BY ' DATE <br /> ADDITIONAL CO*fitkTS: <br /> PHASE II GROUT INSPECTION PRASE III SINAL INSPECTION <br /> INSPECTION BY. :I0 DATE 'INSPECTIONDATE <br /> $ <br /> 1 AA <br /> E H 1426 Rev.. 1-74 <br /> 1-74 2M <br />