Laserfiche WebLink
1, acU1N DISTRICT <br /> C!O£. OFFICE USE: 1601 E. Hazelton Ave. , tockton, Calif. <br /> Telephones (209) 466-6781 ,J <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �/,� � <br /> (Complete In Triplicate) <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 Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District, <br /> JOB ADDRESS/LOCATION 4VI 0 #jP:GCs 4 CENSUS TRACT <br /> Owner's Name / l�'. M Phone <br /> Address . D U City 0 7-,'!i/ _ <br /> Contractor's Name License #2C Phone 4,G[fc5� <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN '/ / RECONDITION /—/ DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR '/ / PUMP REPLACEMENT <br /> Other /—/ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USB TYPE OF WELL CONSTRUCTION SPECIFICATIONS O <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing \. <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary »- Type of Grout <br /> Other Other Information �l <br /> k V <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. /. <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP ' EPAIR: / / State Work Done <br /> ,DF9TRUCTION 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. <br />{ SIGNED TITLE - "�'_„�.�.� <br /> V 4A4 <br /> DRAW PWT PLAN ON REVERSE SIDE) F <br /> r <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> i APPLICATION ACCEPTED .BY DATE, <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE-IIIJFINAT, INSPECTION `l <br /> INSPECTION BY DATE INSPECTION BY DATE 2 <br /> CALL FOR A GROUT INSPECTION PRIOR- TO GROUTING AND FINAL INSPECTION. t <br /> V U I LI)K r�/f7+ 1-m <br />