Laserfiche WebLink
SAN JOAQUIN,721t_JGAV-,HEALTH DISTRICT <br />-FOR-OZg_ �,V2 ,0 FFICE USE: 1601 E. Hazelton ,Ave-.,j, Stockton, CA 95205 Permit No. <br /> Telephone,;;-u t209) 466,4-i6781 <br /> APPLICATION FOR,,,WELLfQNSTRUCTION -OR PUMP PERMIT Date Issued <br /> This •Permi t-iIEAss�jed- <br /> piresj4ea..., from rD,at <br /> Complete-Jn Tri <br /> Application is hereby made to the San Joaqui'n"Ldc'al`l-Htla,l'thl.'Di,Strict for-;a permit to"Cohstruct <br /> d <br /> 64d'� T.his .-.ap,Vl:i:cat.,io�ti;�:�is made: in compliance wth-San b o <br /> and/o>" hbr)e"fin' rescy, <br /> &nCeL� .0. <br /> ' 1862--and the, Rul2,sand-Regulations. of the -San­Joaquin,­Lotal- Heal,th <br /> District. <br /> 2 ITYjtOiAa. <br /> Owner's Name <br /> �S. <br /> EXACT ET,'A6b�t,5, <br /> 94, <br /> 9-A&- <br /> Phone, L 7 <br /> A2ACV, lAt& - - - <br /> ty1_=/_y?10i- <br /> Addfi�s- <br /> Contractor's NameLicense#L??g/Z!j Phone k! <br /> 41 /Z 1.0_1 <br /> IS CERTIFICATE Or wokmAws` tOMPENSATJOH T."NURAITIE O'N FILE, WITH SJLHb? _YES N0 <br /> TYPE OF WORK _(Chedk) : NEW WELLE4 ' DEEPEN 0 RECONDITION C) DESTRUCTION <br /> WELL CHLORINATION 0, WELL ABANDONMENT BANDONMENT E3 OTHER 0' <br /> PUMP INSTALLATION 0 PUMP REPAIR PUMP REPLACEMENT 11 <br /> PIT PRIVY <br /> DISTANCE. TO. NEAREST. SEPTIC TANLk,-< , Lt <br /> b --+ SEWER LINES_ + <br /> SEWAGE DISPOSA4 FIELP5M 1_+ CESSPOOL/SEEPAGE PIT, OTHER <br /> PROPERTY LINWORIVATE DORESJIC; WE�Lc5-a---t-_ P'UBLTC DOMESTIC WELL-=-=:- b <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Di <br /> a. of Well Excavation -2 <br /> bomestit/private —Drilled :. <br /> Gauge <br /> of Well Casing— ;R 6.1 <br /> Domestic/public Driven o� Casing Cl"r, IZA <br /> Irrigation Gravel Pack Depth of Grout Seal -Vit <br /> Cathodic Protection )y Rotary Type of Grout <br /> Disposal 'Other Other Information <br /> Geophysical Surface Seal Installed b <br />� PUMP INSTALLATION: / _Contractor <br /> Type' of Pump H.P. <br /> PUMP REPLACEMENT: []State Work Done <br />' PUMP REPAIR: OState Work Done <br /> DESTRUCTION OF WELL: Well DiameterDepth----, <br /> Approximate <br /> Describe Material and Procedure <br />� I hereby certify that I have prepared this application and ,that the work will be done in accordanc( <br /> with San Joaquin County Ordinances, State LAws, and Rules and Regulatio6s of the San Joaquin Local <br /> Health District. Home owner or licensed agent't sighature certifies the following: <br /> . "I certify that in th-e performance of the work for- which this permit is issued, I shall <br /> not employ any person in such manner as t6 become subject to Workman's Compensation <br /> laws of California." <br /> I WILL CALL FORA jGRO)IT PSWECTION-PRIOR. TO.GROUTING,AND VFINAL INSPECTION. <br /> TLE DATE.2( <br />'SIGNED <br /> �' DR�A�WPL�OTP�L NqTO�N'� REVS RSUSDE <br /> ) <br /> FOR DEPARTMENT USE ONLY <br /> 1PHASE I <br /> APPLICATION ACCEPTED BY DATE—,A�de <br /> ADDITIONAL COMMENTS: 2_7 <br /> PHASE4 II' OUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BYDATE /07 INSPECTION BYDATE'r?- <br /> 1--/7R 7M <br />