Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. HazeltonOAve.' Ogffockton, Calif. / <br /> Telephone:. ;(209)U466r6781 <br /> APP CATION FOR WELL CONS' kUCTIWOR PUMP PERMIT Permit No. <br /> TH S PERMIT 7.;i <br /> . {.Ci�ml'efiyT �pUa x r -� z;• u'l� -�,6 9tI r rT:S <br /> Appy.icat��bidDh&rgb�- de fte bheagam.�Jbaquk-h!ILo&ab ��a3 Mkt D�i���'�Ct_Cfbf��asp��d►�t }ta' r 6�isi��(f�� � <br /> , . -and/or install the work herein described. TI� a;rp3��;csS� mti319 M'm�dein5corttpll3tice 'with? 5�n %�6aquin <br /> I <br /> County a)Qn maiif eoNo glS62rrari Cyt,hasRuke�bandaRegu1aaiionso6f dvY;e,Sangbaqui. x2166a fz'Health�rDi.§tricti. <br /> �-• r : <br /> t .TOB ADDRESS/LOCATIo� .DCSNSLST► AGT a s00rr <br /> W q,o—:`a gj,ia� fill �'U c�01C -9IfI l a f� �. 6 r� c L iia ,r f r �7.d."a 8 r .�a7 9:?f{ s.!? rf4-FT J 71 C <br /> Owner:sK?Nam€�P^ ��r x � ": RIw,�SI.CC)Lhz ISO ,Tasjav,� .6-, <br /> Address /SAO _ City i <br /> Contractor's Name ^P <br /> ............... <br /> License �� hone <br /> _.� <br /> t_.... . . .. <br /> TYPE OF WORK (Check) : . NEW WELPUMP TNSL / DEEPEN /_/ RECONDITION /_ .DESTRUCTION ./� <br /> TALI ATION '/ / PUMP -REPAIR f/ PUMP REPLACEMENT <br /> f . <br /> DIS LANCE TONEAREST'::: <br /> SEPTIC: TANK...: . SEWER LINES— — . PIT PRIVY .,. <br /> �. <br /> '4,. .... .SEWAGE, DI$ROSAL.,.F.IELD ...CESSPOOL/SEEPAGE. PIT : OTHER . . .: <br /> l <br /> JNTENID4T- USE TYPE 0V WELL.; ' ......CON_STRUCTZON�SPECIFICATIONS <br /> _lndustzial:. .. ......... ... .......: .. _Cable .Tool . .. Dia._: f_Well..Excavation <br /> }(T Domestic/p.riv2.te: --Drilled Dia. of Well Casing <br /> Domestic/public a iveri Gauge, fif Casing <br /> 3 -fit rrigation.. :...::.:. GraveL:Pack. - : Depth; of Grout;Sedl ._. <br /> 3 <br /> Othe`r : <br /> - Rotary <br /> Tyke of Grout <br /> Other: Other: Tnoration <br /> r Y <br /> I <br /> 1�-� w <br /> i <br /> 'PUMPINSTALLATION: . ., Co�itractor , - ' �l�d���� . �+-tab <br /> ;.Type. of Pump <br /> : <br /> PUMPSREPLACEMENT; /:/ State Work-Done <br /> t PUM� <br /> REPAIR: <br /> / / State Work Dane t? r,Jm <br /> ,PESTR1jCTION .0�' WELL':: _. Well Diametf r. `:_ -.-Approximate. Depth... .. ... . .s...... <br /> _ I <br /> . : Describe Material 'and` Procedure 3 <br /> t 1 hereby agree .to...cornp. <br /> xrith ,all. .laws and regulations of. the $an .Joaquin Local- Hearth -Distric <br /> and the State' of: Calif brnia gertaiijing to or: regulating well construction. Wi:thiiz FIFTEEN;DAYP <br /> ;aftgr completion: of mq:work on a new wet , I will' furnisii the San'-Joaquinn L661 Health bisirici a <br /> WELD DRILLERS REPORT ..the. well and. notify them before putting the well <br /> in use.. The..above.. .. <br /> 'infdrmation is true tollthe best :of my ,kn6wledgeya belief <br /> . <br /> :SIG ED.' .;. ... LE <br /> LZ PLOT L 0' .... ... . <br /> N RECUERSE 'SIDE) <br /> 3 <br /> ONLY <br /> PHA E I ,.... . ;,. :. :. . k.. ,. <br /> OR DEPARTMENT USE <br /> APPLICATION ACCEPTED IY DATE A-`A 1a2 <br /> - -- <br /> ADDITIONAL COMMENTS;..._. , . ---- <br /> P SE 1I- GROL•TT' INSPECTION PHAS I-II/:FINAL,INSPECTTO , <br /> INSPECTION BY DATE INSPECTION BYDATE <br /> ff <br /> C3ALL FOR AGGRO T: IN PE TIONPRIOR-T <br /> _ _v, C 0 GROUTING AND FINAL INSPECTZO . .v g _ <br /> E H 1426 4/72 1M <br />