Laserfiche WebLink
SAN JOAQUIN LOCAL Rk„ LTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone:. .(209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT I Date Issued,,;,/_j3-?g <br /> (Complete In Triplicate) f,J� tic_ ccp 1 -7� <br /> H�AK <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San <br /> Joaquin County Ordinance No. 1862 and the Rules and' Regulations of the San Joaquin Local Health <br /> District. � 4{-t s5l <br /> J <br /> EXACT STREET ADDRESS 611 El Capitan (Yosemite Park) CITY/TOWN Manteca. <br /> Owner's Name = OF MANTEr-A, Phone 239-9511 <br /> Address 1001 W. Center City Manteca <br /> Contractor' s Name Son vf License# Phone 464-9804 <br /> IS CERTIFICATE OF WQRKr4AN'S CO" PENSATION INSI)RAtirr ON FILE WITH SJLHD? YES x No <br /> TYPE OF WORK (Check) : NEW WELL U DEEPEN ❑ RECONDITION (] DESTRUCTION[] <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION (a PUMP REPAIR M PUMP REPLACEMENT M <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES xx PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE D MESTIC WELL PUBLIC D MESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation 26" � <br /> Domestic/private Drilled Dia. of Well Casing . 16" I.D. <br /> x Domestic/public (City) Driven Gauge of Casing 41T <br /> Irrigation Gravel Pack Depth of Grout Sea T 100' <br /> -Cathodic Protection x Rotary Type of Grout Neat cement <br /> Disposal Other Other Information <br /> Geophysical Sep�._ Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor Henninq Bros. Modesto, Calif. <br /> Type of Pu�mpnirhirtp - H.P. 40 H.P. <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Proce ure <br /> I hereby certify that I have prepared this application and that the work will be done in accordant <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations of, the San Joaquin Local <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 F~p - --GR UT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: , a� DATE: <br /> OR PL L N ON REVERSE SIDE <br /> PHASE I -FOR-5E-PTRTMENT USE ONLY <br /> APPLICATION ACCEPTED BY �� DATE /7f <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III NAL INSPECTION <br /> INSPECTION BY DATE ,� INSPECTION BY �, ,�; DATE f1r idl7Y <br /> EH 14 26 Rev. 9/78 /✓o k �.� c_ G -r, r r� ! y r-or <br /> -?�7 r, /78 2M <br />