Laserfiche WebLink
�.6 SAN JOAQUIN LOCAL HEALTH:I)ZSTRICT <br /> FOEeOFFTCE USE: 1601 E. Hazelton Ave. , 'Stddcktort Calif. <br /> Telephone (209) 466-678-1- <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> f <br /> THIS PERMIT EXPIRES I REAR -FROM°DATE" ISSUED Date Issued <br /> A (Complete in Triplicate) <br /> Application is hereby' made p ) <br /> y to the San Joaquin Local .Realt'h 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. 3862 and the Rule q <br /> Rules and Re <br /> gulations.~of.;the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �� r <br /> A' CENSUS TRACT <br /> Owner's Name Phone <br /> Address Mzv <br /> " City /-0,0V <br /> Contractor's Name ` <br /> License # &Z9jZ Phone"-z�?�� <br /> fl.r c- <br /> TYPE OF WORK (Check): NEW WELL L-_7 DEEPEN /_7 RECONDITION /? DESTRUCTION /7 <br /> PUMP INSTALLATION /gJ PUMP REPAIR / / PUMP REPLACEMENTf <br /> Other /j <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> - SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> OTHER <br /> INNDED SE PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL \ <br /> TEUTYPE OF WELL CONSTRUCTION SPECIFICATIONS V , <br /> -,� Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private DrilledDomestic/pDia. Of' Well Casing (.� ' <br /> Irrigation lic Driven Gauge of Casing � . <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other. Information <br /> Geophysical ` Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor { <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: State. Work Done ^~ <br /> PUMP :REPAIR: f <br /> . /7 State Work Daae- - I <br /> ESjRUCTION OF WELL: Y <br /> We11 Diameter Approximate Depth <br /> Describe Material and Procedure —--- <br /> I hereby agree to comply with all-laws and regulations of the San Joaquin ]1 41 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 d+f the well and notify them before putting the- well in.use. The above <br /> information is true to the-beat of my knowledge and belief. I WILL CALL FOR A GR <br /> PRIOR TO U AND A FINAL INSPECTION. OUT INSPECTION <br /> SIGNED TITLE _ <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE /1) <br /> PHASE ii GROUT INSPECTION �KE I T/FIN INSPECTION <br /> INSPECTION BY DATE �'� `Z_lf96 INSPECTION $ <br /> DATE <br /> E H 1426 Rev. 1-74 <br /> _: 1-74 7M <br />