Laserfiche WebLink
SAN JOAQUIN LOCAL ;HEALIH 01SFRICT _ <br /> FFICE USE: 1601 E. Hazelton Ave. ,f Stoek`Cor», CA 95205 Permit No.�,SO <br /> Telephone: (209) ,466-6781 S i <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued / <br /> This -Permit Expires 1' Year From Date Issued <br /> Complete In Triplicate) <br /> Application is hereby madetothe San Joaquin Local Health District- for a permit to construct <br /> 6� <br /> and/or install the work hereimidescribcd. This 'application is made in compliance with San a, <br />,,oaquin County Ordinance ado. 1862 and the Rules and Regulations of the San Joaquin Local. Health <br /> District. <br /> EXACT STREET .ADDRESS . CITY/,TOWN <br /> Owner' s Name University of the Pacific L s Phone 946-2507 <br /> Address 3601 Pacific -Ave --� � , �. City Stockton <br /> Contractor' s Name Clark Welll & E ulp.Co 6 ,rinc Li cense#76642 Phone 462-559Z ' <br /> IS CERTIFICATE OF WORKMAN'S' COMPENSATION INSURANCE ON FILE WITH SJLHD? YES � T10 <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN❑ RECONDITION gle DESTRUCTION12 � <br /> Cl <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ (� <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT El <br /> DISTANCE TO NEAREST: SEPTIC TANK_±j_oo SEWER LINES +1 oo PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT ,f OTHER <br /> PROPERTY LINE+-1-Q*IVATE DOMESTIC WELL PUBLIC DOMESTIC WELL + # <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial t X Cable Tool Dia. of Well Excavation <br /> �Domestichr-ivate I Drilled Dia. of Well Casing _ ��} O <br /> Domestic/public y Driven - Gauge of Casing 1 <br />�—Irrigation tI Gravel Pack Depth of Grout Seal d ':none l' <br /> Cathodi,c"'Protecti'on 4 I Rotary Type of Grout <br /> Disposal f Other Other Information nrillea 1-934- <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H. . <br /> PUMP REPLACEMENT: Q State Work Done <br /> PUMP REPAIR: ❑Stat Work Done � <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material an2 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 Regulations of the San Joaquin Local <br /> Health District. Home owner or licensed agent' s signature certifies the following: <br /> "I cert' that in the performance of the work for which this permit is issued, I shall <br /> not mploy any pe son in such manner as to .become subject to Workman's Compensation <br /> la s o ifor a. " I _. <br /> WIL CA O I PELTJ�WR— <br /> I TO GROUTING AND A FINAL INSPECTION. <br /> SIGNS <br /> ,� _ � TITLE: Pro-ject Director DATE:, May 30,1979 <br /> ' DRAW PLUT PITN ON REVERSE SIDE <br /> R D RTMENT USE ONLY <br /> 3HASE I <br /> 4PPLICATION ACCEPTED BY rn, DATE 3 j <br /> 4DDITIONAL COMMENTS: i <br /> . PHASE II GROUT INSPECTION PHASE 14L FINAL INSPECTIO <br /> MPECTION BY DATE INSPECTION BY DATE 7.N17 <br /> r <br />:H 14.26 Rev- 12-77 <br />