Laserfiche WebLink
n t <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br />* OR OFFICE USE: 1601 E. Hazelt6r 'Ave:', 'Stackton, Calif. <br /> Teleplibne:­' (209) '46'6-6781 <br /> l APPLICATION FOR,_WELL�-CONSTRUCTION OR PUMP PERMIT Permit No �3_/Sim k. <br /> i <br /> THIS:t`PERMIT 1`EXPIRE5 '.1s;-YEAR FROM DAVE ISSUED'' ' 'Da`te issued.-4----2' <br /> 73 <br /> € (Compete 'In Triplicate) r" <br /> Application °is hereb-►,-'mad,&�,to',t,,hdi n Joaquinztbcal Health District for a``peri� 't fo construct' i� <br /> and/or install the work herein described. This applicatiori 'is made' in 'compl anceiwith San Joaquin} <br /> i E+'1862 art& the -�Ruld's and' Regulations `o <br /> County, Ordifiah <br /> ce',No f the San, x Joaqui Locai 'Health District. <br /> -::!• t !' - ;3-y Y..rf�.:.. '�3o3i :t5_ "X' .s.` -{.c.:}. 3.t , 3 cs r) ,�.-• 3 t ",.s.e s..'v .. I <br /> JOB ADDRESS/LOCATION ZI M 13 ' '' CENSUS 'TRACT <br /> x o' eY r a✓'rd 's F Q 1 <br /> Owner's NamedPho , �r <br /> ne <br /> Address City. <br /> AA <br /> f ,/ <br /> Contractor's Name �/� License 4a`,�� " Phone�i _U4747 ° <br /> LZ <br /> TYPE OF WORK (Check): NEW WELL /R/DEEPEN /7 RECONDITION /7 DESTRUCTION 1'7 gyp, <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 (� <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD _ CESSPOOL/SEEPAGE PIT OTHER <br /> ki <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation !G <br /> Domestic/private' ' Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing ! <br /> __ .- Irrigation ,fA. Gravel Pack Depth of Grout Seal <br /> Other' ''Rotary Type of Grout <br /> Other Other Information A-23 <br /> 1 <br /> PUMP INSTALLATION: ' Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / J ` State'Work Done <br /> PUMP REPAIR: / 7 State Work Done f <br /> I <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, :l 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 rue to the best o.f my knowledge and belief. <br /> SIGNED 44_4� <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY / DATE �7 =� <br /> ADDITIONAL COMMENTS: <br /> PHASE-I; G I S C PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPE ION BY DATE <br /> CALL FOR A GROUT.,,INSPEC ION .PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M j <br />