Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Haze'Ltori.-Ave.-ve'.!�:,- Stoc*lcti-,-,, Calif. <br /> j <br /> Telephone:, (209)='"4W 6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 72- <br /> THIS'PERMIT-EXPIRES lcYEARIFROMDATE ISSUED Date Issued <br /> (Complete InlTriplicate) <br /> Application� is herebyi1nad:eito I-the4SanqJ6aquin-Local Health District for a permit to construct <br /> and/or install the work herein described. This,.applicati:on',is made incompliance with San Joaquin <br /> County Ordinance.-No-;,71852`and the- -Rules!and'LRe gulations"of-'-the San Joaquin Local Health District. <br /> A <br /> JOB ADDRESS/LOCATION <br /> J�, s CENSUS TRACT ' <br /> ao <br /> t.40L 'ri- Mt/S A4,zv,� <br /> Owner!'$ Name -Phone114 X 09 a, 0 <br /> City C-SX-61 <br /> Address ,Q q-1 o -eF <br /> Contractor's Name License # IR <br /> Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN RECONDITION DESTRUCTION -7 -7 <br /> PUMP INSTALLATION JW-7 PUMP REPAIR REPLACEMENT <br /> Other, <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWERI"LINES PIT PRIVY X) <br /> SEWAGE DISPOSAL.FIELD CESSPOOL/SEEPAGE PIT OTHER 1j) <br /> D Q <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ' -!-I <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/priVate Drilled Dia. of Well Casing <br /> X Domestic/public Driven 'Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary- Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor­-�', 01,& H.P. <br /> Type of Pump 1�-Ael <br /> PUMP 149ft I lcefamw: State Work Done rj <br /> PUMP REPAIR: /-7 state work Done <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 of the well and notify them before putting the' w' ell in use. The above <br /> information is true to. the best of my ,klaowledge-aa4d, belief. <br /> SIGN I ED �TLE Ral 1pll <br /> (DPAW LOT AN ON REVRSE SIDE) . <br /> \--,YOR DEPARTMENT USE'ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY WIIN� DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION' PHA§1;2.III4EINAL INSPECTION <br /> INSPECTION BYDATE INSPECTION BY DATE 2-7.A/ <br /> 0­ <br /> CALL FOR A GROUT­INSPECTIONjR1OR_TQ GROUTING AND- FINAI`INSPECTION. 4/72 1M <br /> E H 1,426 re,- <br />