Laserfiche WebLink
SAN JOAQUIN LOCAL REAL 11 :TRiCT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. ,' Stocletsri;Calif. <br /> Telephone: (209) 466-67$��'w' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP .'PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ; Date Issued <br /> " ,Zl�, C�4v "N (Complete In Triplicate) <br /> Application is hereby-made to the San Joaquin Local Health District for a permit to construct E <br /> and/or install the work herein described. This application is made in with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/ ATION l �� /'J � �i- tic` �� G CENSUS TRACT L2S3- a`FQ�D� <br /> Owner's ame -� `(i���� Phone J�c <br /> Addres /Yt i -��i �C� Cit !I <br /> Contractor's Name ,_� �i�fr-��" T .-/�f '-� Licensed Phone PV S.�jcg <br /> TYPE OF WORK (Check) : NEW WELL/ DEEPEN_/._/_ RECONDITION/_T DESTRUCTION: /`7 <br /> `- PUMP INSTALLATION �. / —PUMP REPAIR / / -PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES x�f:_ PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL !T CONSTRUCTION SPECIFICATIONS <br /> IndustrialT o able Cd <br /> x Tool Dia. of Well Excavation <br /> Domestic/private - Drilled' Dia. of Well Casing # i <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation'- Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> I <br /> Other Other Information ' I <br /> PUMP' INSTALLATION: y <br /> Contractor <br /> Type of Pump ---, ,� ._`f _r_. ` c .✓" H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: f_1 State Work Done <br /> DESTRUCTION OF WELL: Well Diameter ` v �� xy.� l��- Approximate Depth <br /> � <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 <br /> DRAW PLOT PLAN ON REVERSE SID <br /> U FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PRASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BYDATE 6 aj24-?3 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M `" . <br />