Laserfiche WebLink
SAN JOAQUIN-Lb <br /> CAL HEALTH DISTRICT <br /> FOR:`OFFICE USE: 1601 E. Hazelton Ave. , St-ockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS 'PERMIT 'EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -� -77 <br /> (Complete In Triplicate) . d SS—I Lf 0 -lam <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 Ord'inance .No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> ,S� Z' W ,-k jG ria�rOOnJ Y <br /> JOB ADDRESS/LOCATION NSUS TRACT <br /> Owner's NameIQ <br /> y1ill <br /> Phone a L Q <br /> Address elf <br /> j _ City . <br /> Contractor's Name <br /> _ � .1� �-, License 1QLPhone <br /> - i <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/—/ RECONDITION /% DESTRUCTION /_ <br /> �- PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /� <br /> CIO <br /> Other ,/ / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY N <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE 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 Driven _ _ Gauge of. Casitig'. <br /> Irrigation Gravel Pack Depth of Grout Seal i <br /> Cathodic Protection Rotary Type of Grout O <br /> ' * Disposal Other ;Other Informati25n " - <br /> Geophysical r _ 'Surf ace Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump # H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> E <br /> PUMP .REPAIR: <br /> / / 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. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO ROUTING AND A FINA-, INSPECTION. <br /> SIGNED rXin TITLE <br /> {DRAtI PLOT PLAN ON REVERSE SIDE j <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE S= �� • � <br /> ADDITIONAL COMMENTS: <br /> r . PHASE II GROUT INSPECTION PRASE III/FINAL INSPECTION <br /> INSPECTION BY. DATE INSPECTION BY R DATE <br /> E H 1426 Rev- 1-74 <br /> 6/77 _ 2M <br />