Laserfiche WebLink
--- SAN JOAQUIN LOCAL H L • �- <br /> FFIC USE: 1601 E. Hazelton Ave. , 02 j, Permit No., <br /> ILA Telephone: (20 <br /> r <br /> APPLICATION FOR WELL CONST1IO5JQRtPRMMRMIT. Date Issued 7- -7� <br /> (Comp l ete I n Tri Ah I OW CAt. c� "(7 <br /> rApplication is hereby made to the San Joaquin Local He is rIc or a permit to construct ' <br /> ,,and/or install the work herein described. This application is' made'in compliance with' San <br /> 'Joaquin County Ordinance No. 1862 and the Rules and- Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS <br /> T' s " CITY/TOWN I <br /> Owner's Name - Phone 2 ay r 2318 <br /> l <br /> Address T City <br />-Contractor's Name o �W�41( License#. Llf..� Phone 2-_29'16 <br /> 'IS CERTIFICATE OF WOPKMANIS CO";PENSATIOM INSURAMCE ON" FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION ❑ DESTRUCTION[] <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION M PUMP REPAIR❑ PUMP REPLACEMENT ❑ 1 <br /> DISTANCE TO !NEAREST: SEPTIC TANK I - SEWER LINES _.., PIT PRIVY <br /> SEWAGE DISPOSI��L� IELD90 + CESSP L/� �SEEPAGE PIT ='OTHER' <br /> PROPERTY LINA +PRIVAT�ESTIC WEL VU. PUBLIC DOMESTIC .WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIE CATIONS <br /> Industrie Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> _ Domest-ic/public Driven Gauge of Casing <br /> ,Irrigation =Gravel Pack Depth of Grout Sea <br />_, ., athodic Protection ,vRotary Type of Grout <br /> Dis oral - <br /> p Other Other Information & «, <br /> Geophysical Surface Seal .InstaTI-ed b <br /> PUMP INSTALLATION: Contractor <br /> l <br /> Type of Pumps H. . " <br /> PUMP REPLACEMENT: []State Work Done_ <br /> PUMP REPAIR: <br /> ❑State Work Done �` n <br /> • � 4 <br /> DESTRUCTION OF WELL: Well Diameters -Approximate Depth <br /> Describe Material 'and Procedure <br /> T � <br />[hereby certify that' I have prepared this application and that the work wi-ll ,be done in accordance. <br /> with San Joaquin County Ordinances , State Laws , and Rules and -Regu-1-ations of the San"Jeaquin Local <br />+ealth `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 i <br /> laws of California. <br /> f WILL CALL FOR G OUT N ECTION PRIOR TO GROUTING AND A-FINAL INSPECTION. <br />;,IGNE <br /> TITLE: ,� DATE: <br /> D PL ON REVERS SIDE <br />'RASE I OR DEpARTM"NT USE ONLY <br /> f <br /> X00-C-ATION ACCEPTED BY DATE ` ' u� <br />,ODITIONAL COMMENTS : cu 4k- a,6; <br /> PHASE .II GROUT INSPECTION <br /> NSPECTION BY PHASE III FINAL INSPEGTION <br /> DATE INSPECTION BY DATE <br /> H 14 26 Rev. 9/78 .,.. <br />