Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. ,'Stocktcn, Calif. <br /> Telephone: (209) 466-6781 i <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 <br /> THIS PERMIT!.EXPIRES I YEAR FROM DATE-ISSUED � Date Issued <br /> (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. 1862 and the Rules and Regulations of ,the San Joaquin Local Health District. <br /> 0 2c -. 0 40 -cam <br /> JOB ADDRESS/LOCATION 4 501 N S Jahant & Mi. E. Tully Road CENSUS TRACT ' <br /> Owner's.Name BLT .Vint rds Bob Luria & Geo .`T Phone ' ' <br /> Address 3-50 Jacguelnlay, Modesto City <br /> Contractor's Name Purvianee Drillers License # pi07 Phone9 <br /> L _ <br /> TYPE OF WORK (Check) :. NEW WELL~'/ / DEEPEN RECONDITION /_ DESTRUCTION /-7 <br /> PUMP INSTALLATION j[ / PUMP REPAIR/ / PUMP REPLACEMENT /� <br /> AL <br /> F Other / / i <br /> w , <br /> DISTANCE TO NEAREST: SEPTIC TANK 300 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 /> Domestic/private Drilled ' Dia. of Well Casing <br /> f Domestic/public Driven . . Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other' Information <br /> PUMP INSTALLATION: Contractor Purviance Dri er -� r .% <br /> Type of Pump Turbine _ _ H.P. 0 <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ,w-... <br /> ,DESTRUCTION OF WELL: Well Diameter T x 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 a best of my knowledge and belief. <br /> � t i <br /> SIGNED TITLE Partner <br /> E (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1�� <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I /FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE '7-2 <br /> CALLIFOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H �1426 4/72 1M <br /> F <br /> E __ <br />