Laserfiche WebLink
FOR OFFICE USE:. SAN JOAQUIN LOCAL, <br /> ' 1601 E. HEALTH DISTRICT <br /> Hazelton Ave. , ,Stocktou, Calif. <br /> A Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Permit No. <br /> THIS PERMIT EXPIRES I Y �--� <br /> EAR FROM DATE ISSUED <br /> Application is Aereb (Complete Tn Triplicate) Date Issued <br /> and/or install the y made to the San Joaquin Local Health Dzstrict for a <br /> Count work herein described. This <br /> County Ordinance No. 2862 application is permit to construct <br /> and the Rules and Regulations of the SaneJoaquomplian compliancewithSan Joaquin <br /> JOB ADDRESS/LOCATIO <br /> E / h Daistrict. <br /> Owner's Name e <br /> CENSUS TRACT /} <br /> Address �S <br /> E 4 <br /> �.. � Phone <br /> Contractor's Name City AGA.M 70 <br /> r - ru�j 'PUMP <br /> y1Gn <br /> -� t � Phone - <br /> TYPE OF WORK (Check) : NEW WELL '/—/ DEEPEN /-7RECONDITION �_� � <br /> PUMP INSTALLATION ./ / _PUMP / / DESTRUCTION /-7 <br /> Other /% / / PUMP REPLACEMENT / h <br /> DISTANCE TO NEAREST: i <br /> SEPTIC TANK � <br /> SEWAGE DISPOSAL FIELDER FINES n. <br /> PIT PRIVY <br /> PROPERTYILINE CESSPOOL/SEEPAGE PIT <br /> TNTENDEb USE - PRIVATE DOMESTIC WELL OTHER h, <br /> Industrial TYPE OF WELL PUBLIC DOM TS IC WELL-`"°` ll <br /> -' -Cable Too-_—. ry_ CONSTRUCTION SPECIFICATTONS <br /> Domestic/private '�'� r. Dia:. of-Well-f <br /> Domestic/public — , Drilled.�t, ,`� -Ufa,_-of_WeI1 Casing <br /> Irrigation �_� Driveri: _ Gauge of Casing <br />--� Cathodic Protection �= Gravel' Pack Depth of <br /> --Rotar p Grout Seal <br />---Disposal y: Type of Grout <br /> Geophysical — Other ------- Other._Information <br /> Surface Seal Installed B <br />'UMP INSTALLATION: ' - <br /> Contractor - m <br /> Type of Pump >" <br /> UMP REPLACEMENT: StaH.P. <br /> e <br /> UMP°:REPAIR: � Work Done w �� � <br />��---� Statj Work Done <br />;S-TRUCTION OF WELL: <br /> 'f <br /> i <br /> Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> l I <br /> hereby agree to comply with al]. Taws and -regulations of the San Joa <br />•d the State of California pertaining to or regulatin �,, quire Local Health istrict' <br /> ter completion of my work on alnew well, I will furnish the San Joaquin Local Heal <br /> LL DRILLERS REPORT of the well and notify them before i eche Sa Joaq i n� Within FIFTEEN DAYS <br /> formation a to the best of m ore putting the -well in use Health District' s <br />[OR TOG y knowledge and belief. The above <br /> A FINAL INSPECTION. TWILL CALL FOR A GROUT INSPECTION <br />,�NED <br /> TITLE l <br /> I > (DRAW PLOT PLAN ON REVERSE SIDE <br /> LSE I OR FART <br /> T USE ONLY <br />'LICATION ACCEPTED BY? <br /> IITIONAL COMMENTS:,, DATE <br /> PHASE II GROUT INSPECTION <br /> PECTION BY <br /> PHASE III/FINAL N <br /> DATE I I <br /> SPECTION <br /> INSPECTION BY DATE i <br /> E H I426 Rev. 1-74 <br /> i <br />