|
• SAN JOAQUIN LOCAL HEALTH DISTRICT - -
<br /> k, FOAr-OFFICE USE: 16Q1 E. Hazelton .Ave St0dkton, Calif. S/�%
<br /> • s 5 f
<br /> Telephone: x''(209) 466'6781 7
<br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit 'No. 7-S---_?,f1
<br /> /
<br /> THIS1?ERMIT. EXPIRES 11'EAR;: Y
<br /> FROM�DATE,.IBSUED �gQDateg Issued° ?T `
<br /> l :"wr :� F AC9mplete�Tn ,T 9
<br /> �' zigl irate)
<br /> Application is hereby made to the San Joaquin`.`Lona1.,,Haa th:D etrict'.fo $;petmit to=construct
<br /> and/or,install�the work herein, described.F,,;This wapplication �js_made$in:,compliance with-San Joaquin
<br /> County"OrdinanceNo. 1862;fiand the. ;R es-=and ,Regulations`;Aof 'the-,'San Joaquin-Local Health District.
<br /> JOB ADDRESS/LOCATION,
<br /> R ; , _ CENsus.dTRACT &S� z� Y
<br /> r"Y� Y s...�� �,41� .$�d°� '� ..a.g-.�+.p 4Fu � -��i:^ ? �,t� ,J- ... 2�.,� ;.M.-_F;- � �' ~o!
<br /> Owner s 1 Name r< ,. ._ T w .i�j,
<br /> i
<br /> � Phone
<br /> Address `
<br /> A-
<br /> 'Citq
<br /> CotracCOr's .Name10
<br /> Licei:se
<br /> OtCtd,Phond i
<br /> l'
<br /> TYPE OF WORK (Check):" NEW WELL:/ -7DEEPEN;'I7 "RECONDITION /,77 DESTRUCTION"/ f F ~
<br /> PUMP`INSTALLATION, cIMP REPAIR
<br /> i # , O thea l/,/ PUMP. REPLACEMENT. `/-7.
<br /> O
<br /> t
<br /> DISTANCE TO NEAREST SEPTIC TANK �4
<br /> s . SEWER,LIVES ; PIT PRIVX
<br /> SEWAGL DISPOSAL FIELD: CESSPOOF:/SEEPAGE PITS
<br /> P OTHER f� 'J
<br /> 'PROPERTY 'LINE - PRIVATE DOMESTIC--WELV' .. PUBLIC DOMESTIC WELL
<br /> I 'INTENDED USE
<br /> STYPE OF WELL
<br /> i Industrial s ' ... ,CONSTRUCTION ,SPECTFICATIONS cc
<br /> --�-- I�Cab;Ie Tool Dia. af ;Well Eaccavation C .
<br /> "Domestic/private Drilled Dia. of Well Casing
<br /> Domestic/public. -z.,Driven��, F I
<br /> ' ;Irrigation ., . Gauge of Casing- —�..___.._
<br /> ,Gravel Patk Depth of Grout: Seal.
<br /> Cathodic Protection r t~ `Rota,
<br /> oral y Type ,of .Grout g
<br /> Disp r i- Other �: Other Information'
<br /> Geophysical, i
<br /> Surface Seal Installed B —
<br /> PUMP INSTALLATION:: t Contractor y � "
<br /> Type 'of .Pump ^ ��
<br /> PUMP REPLACEMENT: j ' H•P• ��
<br /> t / / State Work. Done 7
<br /> PUMP-'iEPAIR: „� !State Work
<br /> Done
<br /> ES
<br /> RUCTION OF WELL:
<br /> Well Diameter
<br /> Approximate
<br /> [ r Describe =Materia]. and Pr0 Depth
<br /> cedar
<br /> e ,
<br /> I hereby agree to com l
<br /> p y with a1J Saws and regulations of the San.Joaquin Local Health District' }
<br /> and.-the State of California pertaining to or regulating well'cbnstrtictioh. Within FIFTEEN DAYS
<br /> after completion of .my. work.;on a.,newyeZ1,,.,I.wi1l furnish. the .SansJ.aaquin Local Health District a
<br /> WEILLi DRILLERS REPORT of the Well and notify ithem befoze putting..the .r+iell ia,use,. h"
<br /> PRIOR information is true to the best°of my'knowledge arid' 'belief'. I 'WILL"CALL FOR A.GROUTeINSPECTION }
<br /> SIGNED 0 GR NG AND A FI INSPECTION. N `
<br /> TITLE
<br /> Y (DRAW PLOT :PLAN'ON'REVERSE SIDE) -
<br /> PHASE Y ,FOR DEPARTMENT USE ONLY
<br /> APPLICATION ACCEPTED' BY ` ' E i J .
<br /> ADDITIONAL COMMENTS: J- DATE f �_
<br /> PHASE ' O,UT IN CT 0
<br /> INSPECTION BY ' PHASE III FINAL INSPECTIO+y
<br /> DATE
<br /> INSPECT10N BY
<br /> DATE
<br /> `�E H 1426 Rev. 1-74 {�,n, � �A
<br />
|