Laserfiche WebLink
HEALTH <br /> Cd Ia �a SAN JOAQUIN LOCAL StocktoDn�SCAIC95205 [Date <br /> mit .NO. <br /> FFICE USE: 1601 E. HazeltonAve.' ,, <br /> Telephone: (209) ;466-6781 Issued <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This PermityEx ires 1 Year From Date Issued.. <br /> C,ompl,ete I n Trip i cafe <br /> b made to the San Joaquin Local HealthDistrictfor ampermit liancetwithconstruct <br /> Application is herebyis in <br /> and'/ar install the work herei]g62sandbthe Rules an dlRegulationsmofethe San Joaquin Local Health <br /> Joaquin County"Ordinance Na �r-,o <br /> District. e . � � CITY/TOWN <br /> EXACT STREET ADDRESS ► ' A f«s' a40 <br /> Phone <br /> Owner's Name - �.,,� Ci ty .. <br /> Address �" '= <br /> a License# --Phone Aap <br /> Contractor' s Name <br /> I5 CERTIFICATE OF 1d01'MAN S CO"4 SAT O.! I4�SURA�lCE ON-FILE WIT 4 5JLHD? <br /> TYPE"OF WORK (Check) : NEW WELL 0 DEEPEN ❑ WELLABANDONMENT � DEOTHERT❑N[j <br /> WELL CHLORINATION Q <br /> PUMP INSTALLATION ❑ PUMP REPAIR 50 PUMP REPLACEMENT 0 <br /> SEWDISTANCE TO NEAREST: SEPTIC TANK <br /> POSAL FIELDER LINECESSPOOL/SEEPAGEPIT YPIT_T_____ OTHER <br /> SEWAGE DISMESTIC <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL------ PUBLIC, DOPECIFiCATI0N5` <br /> INTENDED USE TYPE OF -WELL CONSTRUCTION <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic private Drilled Dia. of Well Casing <br /> .` Domestic/public Driven � Gauge of Casing <br /> Irrigation ,c Gravel Pack Depth of Grout Seal <br /> Cathodic Protection �. Rotary Type of Grout <br /> Other Other Information <br /> Disposal — Surface Seal Installed b : <br /> Geophysical <br /> PUMP INSTALLATION: Contractor H,p, <br /> Type of Pump <br /> ' PUMP REPLACEMENT: F]State Work Done f <br /> PUMP REPAIR: (RState Work Done - <br /> _ . - Appr'oxmate Depth-""""" <br /> DESTRUCTION OF-WELL:" _ <br /> Describe mMaterial and Procedure <br /> tht the workk r <br /> in <br /> I hereby certify that I have prepared this application aSdandaRegulationswoflthe SaneJoaquinord Loc <br /> with San Joaquin County Ordinances , Laws ,y and <br /> ignture <br /> th <br /> ies <br /> Hearth District. Home owner or license thenworksforawhichcthisfpermiteisotissued, I shall <br /> "I certify 'that in the perfonnance <br /> not employ any person in such -manner as to become subject to Workman' s Compensation <br /> laws of California." <br /> I WILL CA L FOR A GROUT IN P I R • <br /> GROUTING AND A FINAL INSPECTIONDATE:, <br /> E: <br /> SIGNED W L L N REVERSE SIDE <br /> FO DEP RTMENT USE ONLY <br /> I <br /> PHASE I DATE 7 '79 <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE III FINAL INSPECTION <br /> PHASE II GROUT INSPECTION INSPECTION BY DATE IZ- - � <br /> INSPECTION BY DATE F <br /> � 2] <br /> rrenc In— 4'9_77 <br />