Laserfiche WebLink
. . <br /> �- SAN JOAQUIN LOCAL HEALTH D-ISTRICT ' <br /> -FOR OFFICE USE: 1601 E. Hazelton Ave., Stockton, CA 95205 Permit .No. '-77- ? <br /> Telephone: (209) ,x#66-6781 <br /> APPLICATION FOR WELL CONSTRUCTION 'OR PUMP PERMIT Date Issued 7—a- �� <br /> a <br /> (Wmpiete .In ,Triplicate:) <br /> Application' is hereby made to the San Joaquin Local Heailth PisItrict for a permit to construct <br /> and/or install the work herein described.. This application' is'made fn compliance :w.tth San <br /> Joaquin County Ordinance No. 1862 and the-Rules and Regulations,, of the San Joaquin Local- Health <br /> District. <br /> EXACT STREET ADDRESS ✓v�' ,.�" ?. � :/' n ,� CITY/TONIN <br /> Owner's Names/�, ,,. „� 1 Phone <br /> Address . >ie City, � <br /> Contractors Name 1t.,)f1'/' AjjejLicense# 1.1''"Phoit <br /> IS CERTIFICATE OF WORKMAN'S C PENSATIO"t TrtSURA;'10E ON FILE WITH JLHD? * YES ` N <br /> ` TYPE OF WORK (Check) : . NEW WELL 0 DEE-PEN.Q RECONDITION ❑ DESTRUCTION( <br /> WELL CHLORINATION0 WELL ABANDONMENT —1 OTHER 0 <br /> r <br /> PUMP INSTALLATION C3 PUMP REPAIR M PUMP REPLACEMENT El <br /> . DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT 'PRIVY <br /> SEWAGE DISP SCALL` F ELD C ,S ' L/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVAESTIG WELL PURL C DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. Of Well, Excava't,ion <br /> Domestic/private` Drilled Dia. of Wel Casi�tcJ � <br /> Dpmest c-jp6b!,1 c Dri en Gauge of Casing', <br /> tri <br /> 'at <br /> i Gravel' Pack Depth of Grout SeaA. <br /> -� . O . <br /> Cathod':i'c' Protection Rotary Type of' Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal In stalled by: <br /> a. <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H <br /> PUMP REPLACEMENT-.. ;]State Work Done <br /> PUMP REPAIR:', ( state Work Done ` <br /> DESTRUCTION OF WELL: Well DiameterAppro*i'mate ,Depth_ <br /> Describe Materia an race ure <br /> TI hereby certify that I have prepared this application and ,that the work stili -be done in accor <br /> .with San: Joaquin County .Ordnances,, State laws, and Rul,es.yand Regulationsxof the San Joaquin _Loca <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 06lr, <br /> not employ, any.,,peron i n such manner as to become'° subject to Workman':s Cawrpensation .� <br /> laws of California. <br /> T WILL CALL FOR A­GROUT INSPECTION P TO GROUTING AND A FINAL INSPECTIONr <br />.:SIGNED " ' TITLE: ADATE: <br /> �,LDRAW PILOT PLAN—DN­REVERSE SIDE) <br /> 1.ORDE1 E ONLY <br /> PHASE I <br /> APP'?CATION ACCEPTED BY „ „ DATE ` <br /> _. :. . <br /> ADDITIONAL COMMENTS:, <br /> PHASE II GROF'T 'INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY ,DATE INSPECTION BY DATE <br /> EH 14 26 Rev. 9/78 <. r... 5/79 2M <br />