Laserfiche WebLink
1 � M <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0�-OFFICE USE: 1601 E. Hazelton Ave. , Stockto'i, Calif. <br /> Telephone: -(209) 466=6781 <br /> APPLICATION FOR WELL-CONSTRUCTION OR PUMP PERMIT Permit No. 7,? -3Z2 <br /> THIS PERMIT EXPIRES 1-YEAR FRO14 DATE "ISSUED Date- Issued <br /> (Complete In' Txiplicate) <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 andJthe Rules and Regulations of the San Joaquin Local Health District, <br /> .TOB ADDRESS/LOCATION c_a�a; �D• �c r R Q i­ A,,t_ CENSUS TRACT <br /> Owner's.."Name!T 'hone NAf 3 <br /> Address � � <br /> .? 5- / S . -city ,.7 Cllf _ CII= <br /> C <br /> Contractor's Name / T X190SS 21c), Laf,S S 7C,41- 7"C&ty/.icense # lg4, -g2 Phone74 <br /> TYPE OF WORK (Check) : INEW WELL/y/ DEEPEN / / RECONDITION ./—/ DESTRUCTION <br /> _ /_7N <br /> `PUMP INSTALLATION'"/'- /' PUMP'.REPAIR,/ /=PUMP REPLACEMENT /? <br /> `Other <br /> DISTANCE TO NEAREST: SEPTIC TANK Grp` SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <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 Casing %Z <br /> Irrigation Gravel Pack Depth of Grout Seal ,-o <br /> Other Rotary Type of Grout <br /> IM Other Other Information <br /> PUMP INSTALLATION: r Contractor �' _ <br /> f <br /> Type of Pump H.P. _ <br /> f r <br /> PUMP REPLACEMENT: % / State Work Done <br /> PUMP REPAIR: I� <br /> / / State Work Dane <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 ofl�: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 /> IM `(DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYDATE S" l <br /> s .. <br /> ADDITIONAL COMMENTS: <br /> PHA T INSPECTION PHASE INSPECTION. <br /> INSPECTION By IM DATE INSPECTION BY <br /> DATEL1" <br /> CALL FOR A NSBECTION PRIOR..TO. GROUTING AND FINAL INSP <br /> E H 1426 4/72 1M# <br />