Laserfiche WebLink
SAN JOAQUIN LOcl,{-' EALTH DISTRI-CT <br /> E FFICE USE: I60I E. Hazelton Ave: tockton, CA 95205 Permit No`. <br /> Telephone: (209) 466-6781 <br /> +, APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Ex ires: I Year From Date Issued <br /> Complete In .Trip1 icate = - <br /> Application is hereby made to the San-Joaquin Local„ Health District for. a .permit. to construct, <br /> Land/or install the work herein described. .Th.is€application is made in compliance with San <br /> ric County Ordinance No... 3862 and the Rules <br /> Dist :andAR'gulations of the San Joaquin Local Health � <br /> District. <br /> MirE -%IrO W WIM&A 2O r20n% NwJ Zai <br /> EXACT STREET ADDRESS 1�T MAO) Sifir �� T _ CITY/TOWN -1N�E�! <br /> Owner's Name ,�T,yti�z. o�z cS R/zo �p J;V_ Phone <br /> AddressSf?Or (-4ra ,fi r .ate <br /> ei ty L/its <br /> Contractor's Name v/i5t1✓CE Mice=se' OS + Phone rd'7 341,. <br /> IS' CERTIFICATE OF WORKMAN'S COMPENSATIOIN INSURXNCE ON FILE WITH SJLHD? - YES NO <br /> i YP E-0 F—W0 R-K_(C he c-k-) N Qd_W-E-L L 0=•--�D E-£-PIN-1 _R E-C-04D I44.8 <br /> .N-Qom -DEST.RU.C1WN.Q-,., <br /> WELL CHLORINATION Q WELL ABANDONMENT 0 OTHER 0 <br /> -PUMP INSTALLATION El PUMP REPAIR❑ PUMP REPLACEMENT 0 <br /> DISTANCE TO NEAREST: SEPTIC TANKY2Oo rSEWER LINES-;x S d PIT PRIVY N <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER ” <br /> PROPERTY LINE -, PRIVATE DOMESTIC WELL PUBLIC DOMESTIC .WELL <br /> INTENDED USE <br /> I TYPE OF WELL CONSTRUCTION SPECIFICATIONS. . <br /> Industrial �!Cable Tool Dia, of We11X <br /> x` Ddmestic/private Drilled va_tio/nc� it- <br /> Dia. eCasing <br /> ^ Domestic/public Driven Y © �.'� <br /> Gauge of CasingIrri <br /> Irrigation Gravel Pack 9 <br /> ' <br /> Depth of Grout Sea] <br /> Cathodic Protection Rotary Type -of Grout <br /> Disposal Other <br /> Geophysical � Other Information <br /> Surface Seal ' Installed b : <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: []State Work Done } <br /> PUMP REPAIR: Q State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> ,,,Describe,-Materia.-an ,P.roce ure- - APproxima a Depth <br /> --A <br /> I hereby certify that I have prepared this,application and that the work will be done in accords <br /> with San Joaquin County Ordinances , State Laws, and Rules and Regulations of the San Joaquin Lol, <br /> Health District. Home owner or licensed agent's signature certifies the following: <br /> "I certify that in the performance of the work for which this permit is issued, I shall <br /> not employ any person in such manner as to become subject to Workman's Compensation <br /> laws of California. " <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING ANDA FINAL INSPECTION. <br /> i IGNED ,/ <br /> TITLE: pin�NC, _ -DATE: <br /> W PLOT PLN ON REVERSE SIDE <br />'RASE I" .. 'FOR DEPARTMENT USE ONLY <br /> lPPLICATI6E ACCEPTED BY DATE <br /> 0 DITIONAL COMMENTS : <br /> PHASE''I-I GROUT INSPECTION oe <br /> NSPECTION BYPHASE III FINAL INSPECTION <br /> DATE 5 INSPECTION BY <br /> - <br /> a <br /> DATE <br />