Laserfiche WebLink
g SAN JOAQUIN' LOCAL HEALTH. D.ISTRICT <br /> t FFICE SSE: 1601 E. Hazelton' Ave. , Stockton, CA 95205 Permit No. <br /> r M_7�L <br /> Telephone: ('209) 466-6781 <br /> APPLICATION FOR 'WELL CONS' 67I0N OR PUMP PERMIT Date Issued 7-10..79 T <br /> (,Complete In Trip]°icate'). <br /> j Application is herebymade to the San Joa u i,n Local Heal th-Di stri c.t for a Oermi t to' construct <br /> q p <br /> E .and/or instal.,] the work herein described This application-is -made In compliance with' San <br /> Joaquin County Ordinance No. 1862 and the Rules and: RegulationsSan Joaquin Local Health <br /> bi stri ct. I� <br /> ;EXACT STREET ADDRESS '� �t �a ,� CITY%TOWKIL5" <br /> Owner's Name Phone <br /> Address _ I� <br /> - ., _ City- .. . \ <br /> Contractor's Name <br /> Li <br /> cep s Phone= <br /> IS CERTIFICATE 'OF WORKMAN'S COMPENSATION INSUR CE ON FILE WITH SJLHD? YES �� 0 <br /> TYPE OF WORK (Check) : NEW`WELL DEEPEN 0 RECONDITION DESTRUCTION 0 <br /> WELL CHLORINATION Q ELL ABANDONMENT 0 OTHER C> � <br /> ! PUMP INSTALLATION ,C PUMP REPAIR❑ . PUMP REPLACEMENT [ " y <br /> DISTANCE TO NEAREST: SEPTIC TANK/)Q -SEWrER LINES bO_. IP T PRIVY <br /> f SEWAGE DISPOS IELD,, CESSPOOL/ G PIT 2 OTHER <br /> PROPERTY LIN IVAsTE DOMESTIC. WELL PUBLIC .DOMESTIC_.-WELL <br /> INTENDED USE �� TYPE OF WELLM CONSTRUCTION SPECIFICATIONS <br /> IndustrialCable Too`] ";Dia. of Wel Excavation <br /> omestic/private i11ed .1. f Dia, of Well-..Casing � <br /> Domestic/public 1 Driven Gauge of Casing <br /> 4�-'Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection rotary Type .of Grout -- r <br /> Disposal Other I� Other Information <br /> Geophysical /Surfs a Seal Installed b <br /> PUMP INSTALLATION: Contractor <br /> + <br /> Type of Pump H. . .� <br /> r v <br /> PUMP REPLACEMENT: rJ State Work Done. _ . . <br /> PUMP REPAIR: QState Work';Done-.. A s <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe MaterTaFariZIPrEcedure <br /> I hereby certify that. I 'have prepared this appl i cation and that the work:wi l.1 be done in accordant <br /> With San Joaquin County Ordinances, State Laws ;:•a,nd�Rules and Regulations 'o.f the San Joaquin •Local <br /> Health District—' Home owner or licensed agent'sjsig'iature certifies the foilowing: � <br /> J certify that in the performance of the;lwork for which this permit is issued, 'I shall <br /> not employ any person in- such-a.manner-�as-to--become subject to WDrkman's Compensation <br /> laws of. California."Il. <br /> I.' WILL CAL FOR.A_ qRQUTJNSPECTION PRIOR TO :GROUTfING AND 1A'Fi AL -I SPECTION. <br /> TITLE,: <br /> KAW PL ON REVE .SE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> r PHASE I. <br /> APPLICATION ACCEPTED BYY DATE <br /> ' ADDITIONAL COMMENTS; ;� y <br /> v PHASE I GROUT INSPEGTI N PHAUIlIjJINAL INSPECTION <br /> INSPECTION BY DATE �� INSPECTION BY DATE 0 001 <br /> EH 14 26 Rev. 78 �� - - ...,. <br />