Laserfiche WebLink
G� SAN JOAQUIN s HEALTH DISTRICT <br /> FORIOFFICE USE: 1601 E. Hazelton Av61 ' Stockt'on, Calif. <br /> "I Telephone: (209) 46.`6-6781• t <br /> APPLICATION FOR WELL CONSTRUCTION. ORIPUMP PERMIT Permit No. 74 C.J <br /> Y 'j. <br /> THIS: PERMIT EXPIRES I YEAR°FROM 'DATE ISSUED Date Issued }/4 76 <br /> t (Complete In.Triplicate) <br /> Application is hereby made to.-the San Joaquin Local-`Health- Distitict for a permit- to construct <br /> and/or .install, the work herein described. This applicati:on.'is made in compliance with San Joaquin <br /> County Ordinance Na. 1862. andj'the Rules and Regulations-of°the=San Joaquin Local Health District. ; <br /> JOB ADDRESS/LOCATION;_, . v2 P� � ?-'. 4 O+�r CENSUS TRACT <br /> Owner Is Name �e 1 D �1 �/ La / l S.. _.. Phone //77 <br /> ZZZ <br /> Address City ,� r�c'_l�'/r <br /> Contractor's Name [rl License #4 Phone x �-J <br /> 1 <br /> TYPE OF WORK (Check): ,-N L DEEPEN -/ RECONDITION /? DESTRUCTION f7 <br /> P S LATION f_1 PUMP REPAIR /7 PUMP REPLACEMENT 17 <br /> 0 <br /> DISTANCE ,T NEAREST: SEPTIC TAINK SEWER LINES PIT PRIVY <br /> SAGE D SPOSAL-FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> P PE LINE - P STIC WELL PUBLIC DOMESTIC WELT. <br /> INTENDED E F C PECIFICAT ONS <br /> Indorial - D 11 Excavation <br /> Dourest c/prt '` 4- Drilled Dia. of We 1 Casing <br /> Domes-ti publi• o asi <br /> Irrigati r Gravel Pack Depth of out Seal <br /> f Cathodic P otection { — Rotary Type of G out <br /> Disposal I Other Other Inf rmat on <br /> Geophysical a Sea ed B <br /> PUMP INSTALLATION: Contra `tor.. <br /> Type o Pump H.P. <br /> PUMP REPLACEMENT: Sta Work Done . <br /> PUMP;'_REPAIR:_,_,, ,,,,,,�. <br /> E&TRUCTION OF WELL: Wel :Dia Appro mate Depth <br /> De � t rial and Procedure <br /> I hereby agree to comply with al ga and regulations of the San Joaquin oca Health District <br /> and the State of California p ton to or regulating well construction. i hin FIFTEEN DAYS <br /> after completion of my work ori a n w 11, I will. furnish-the San 'Jbagiuin�Local Health District a <br /> WELL DRILLERS REPOAT. of the wet an, n tify the>a./before putting. the. well in use, The above ' <br /> information is. true to the be9t. y owledge and belief. I WILL CALL FOR A GROUT INSPECTION,. <br /> PRIOR. TO GRO TING FIN <br /> IN <br /> ECTIO ; <br /> SIGNED TITLE '�� Y <br /> �+ (DHA PLOT PLAN ON REVERSE SIDE <br /> OR :DEPARTMENT USE `ONLY <br /> PHASE I F <br /> APPLICATION ACCEPTED BY-, a " r DATE <br /> ADDITIONAL COMMENTS: 1 1 <br /> PHASE II GROUT INSPEC ION PHASE III/FINAL INSPECTION" <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> - E H,1426 Rev. 1-74 1-74 2M <br />