Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT F <br /> OR EFICE USE: 1601 E. Hazelton Ave.,St ckton, CA 95205 Permit No. 7 9-96 f <br /> Telephone: (209) 4 2 - -' <br /> ---- APPLICATION FOR WELL CONSTRUC <br /> % I Rie Issued ) /& ? <br /> WOW <br /> Application is hereby made to the San Joaquin Local. Healttfflermit -to construct <br /> and/or install the work herein described. This applicatio , I pli:ance with San. <br /> Joaquin County Ordinance No. 1862 and the Rules and R gula ions of the San Joaquin Local Health <br /> District. A)0 + 129W5 ��ti� C'� � ledclml <br /> EXACT STREET ADDRESS CITY/TOWN A+.,,•,/" �C' i4 <br /> Owner's Name Phone' �- <br /> Address / City. .: ,f Al- <br /> Contractor's <br /> Contractor's Name z2a Li cense Phone` -Z-.Zf-,1 0._ � <br /> TS CERTIFICATE OF WORKMAN'S CO"r1PENSATI-Oti,--IPJSURA�iCE- ON"FILE WITH`SJLHd?` YES qO <br /> TYPE OF WORK (Check): NEW WELL CX DEEPEN CI RECONDITION DESTRUCTION( , <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION 0 PUMP REPAIR❑ PUMP REPLACEMENT [] <br /> DISTANCE TO NEAREST: . SEPTIC :TANK/ SEWER LINES_ .., . PIT PRIVY �- - <br /> SEWAGE DISPOSIELD 6 r CES PMOL/SEEPAGE PIT OTHER <br /> { TY <br /> PROPER LIN f PRIVATE DO ESTIC WELL,Z� PUBLIC DOMESTIC WELL --- <br /> . I INTENDED USE + TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Wel Excavation `f <br />��Domesti c/private Drilled Dia., of Well Casing <br /> s� <br /> Domestic/public i Driven Gauge of Casing <br /> &i-gation __Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout <br /> OIL- <br />-7—Disposal Other -Other Information �-�--- j <br /> µ Geophysical Surface Seal Installed -by: <br /> PUMP INSTALLATION: Contractor - <br /> Type of Pump H,.P. <br /> PUMP REPLACEMENT: Q State Work Done _ I <br /> PUMP REPAIR: OState Work Done , <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material ana Procedure <br /> I hereby certify that I have prepared this application and that the..work will be- done in accordance <br /> with San Joaquin County Ordinances, State Laws, and Rules and-Regufations 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. FOR A f7ROUJF INgTION PRIOR,TO 'GROUTING AND A FINAL INSPECTION. .._ <br /> S?IGNED <br /> . TITLE: DATE: <br /> (DRAW PLOT PLANON REVER SIDE <br /> Y OR DEPARTMENT USEONLY, <br /> PHASE I - <br /> APPLICATION ACCEPTEb BY �� a-, DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPECTION <br /> INSPECTION BY DATE ' INSPECTION BY DATE (6 -4- <br />:E H <br /> 6 -:EH 14 26 Rev. 9/78 -; wvc, ,� /v. ---� 9/1 M1 <br />