Laserfiche WebLink
SAN JOAQUIN LOCAL I:IEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockto,z, .Calif. t. <br /> Telephone: (209) 466-6781 x" <br /> r., <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> j <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED , Date Issued <br /> tj (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 /> County Ordinance No. 1.$62 and the Rules -and Regulations of the San Joaquin Local Health District, <br /> JOB ADDRESS/LOCATION ei ,r'/l/,e-x 01Z_1 Ll�f A&)4 emnIt JJS CENSUS TRACT <br /> g <br /> Owner's Name 'iC L/ D Phone ,�6,1-� _ <br /> Address _ /(1257 N 4 Lgz&1� A0- L.oaz Coo - -- City L..O w-, <br /> Contractor's Name �Q FLL �iPiLL/ / _ - �p(� ,oC License # //7.2,f/ Phone <br /> TYPE OF WORK (Check): NEW WELL jg�DEEAN /_7 RECONDITION / / DESTRUCTION /_ <br /> PUMP INSTALLATION /ryf�PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> 0 then /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> woft <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ? <br /> Industrial ��fable Tool Dia. of Well Excavation /1PL" <br /> Domestic/private Drilled ' Dia. of Well Casing RA# <br /> _ Domestic/public Driven Gauge of Casing <br /> _JGlrrigation Gravel Pack Depth of Grout Seal Im lh/!!maw s <br /> Other Rotary Type of Grout !ZIA am-ffil: <br /> Other Other Information ' <br /> PUMP INSTALLATION: Contractor r <br /> Type of Pump I H.P. ,x i <br /> PUMP REPLACEMENT: / / State Work Done <br /> i <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 TITLE r��Al <br /> (DRAW PLOT PLAN ON REVERSE SIDtj— <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE -/7-7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY /,?,P DATE .�S-� INSPECTION BY DATE 7x� <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />