Laserfiche WebLink
USE: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFiCE <br /> i; 1601 E. Hazelton Ave.', Stockton,- CA 95205 Permit No. ' - 5"7 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Expires- 1 Year From Date Issued <br /> Gomp,]ete �In Tri pl i cafe <br /> Application: is hereby made to the San Joaquin Local Health District for 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 4 Muer r'l u t ' <br /> Owner's Name ,�"�/', �[ E �, � . <br /> CITY/TOWN .�"�QCMLA <br /> { Address �.� C7 Phone <br /> t e� Dr,' City ST O CI jQ <br /> Contractor's Name "' ' <br /> C.C.A�RIC WE'LL F liiu <br /> cense# 02 Phone Z—S'� "] <br /> _IS .CERTIFICATE OF I-l"KMAN'S COMPENSATIO't ItISURANCE OW FILE WITH SJLHD? YES NO ` <br /> TYPE OF -WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION <br /> WELL CHLORINATION { WELL ABANDONMENT DESTRUCTION(:] <br /> ri N <br /> PUMP INSTALLATION E1 PUMP REPAIR o PUMP Y <br /> I REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TA'Itjgg r SEWER LINES,Zajo �PIT PRIVY --� <br /> SEWAGE DISPOSAL FIEL /dd / CESSPOOL/SEEPAGE PIT OTHER e"�-- <br /> '-PROPERTY LIN9136 PRIVATE DOMESTIC WELLt(cd' PUBLIC—DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL -- CONSTRUCTION SPECIFICATIO <br /> ndustriaT Cable Tool '� ' Dia. of We 1 Excavation <br /> Domestic/private Drilled <br /> Domestic/public Dia, of Well Casing <br /> Driven Gauge of Casing pL- <br /> Irrigation :ravel Pack Depth of' Grout Seal r <br /> = Catho'di c Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Sea] Instal led b : 1` <br /> PUMP INSTALLATION: Contractor <br /> Type of Pumper <br /> t H.P. <br /> PUMP REPLACEMENT: Q State Work Done <br /> PUMP' REPAIR:J ; ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter } r� <br /> Describe Material and Procedure ' Approximate Depth 1 <br /> . wi <br /> I hereby certify that I have prepared this application and that the workwill <br /> be- in a <br /> with San 'Joaqui.n County Ordinances , State Laws , and Rules and Regulations ofthe 'SaneJoaquinoLocalE <br /> Health District, dome owner or licensed agent's signature certifies theo1'low�ng <br /> I certify that in the performance of the work for which this permit is issued," I shal-1 ; <br /> ,not employ any person in such manner as to become subject to Workman's Compensation - £. <br /> laws of:California." <br /> I WILL CALL :.FOR 'A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. � � � <br /> SIGNED <br /> TITLE: OWA, DATE-,:Z�rgz # <br /> DRAW PL T PLS ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> 4 f <br /> APPLICATION ACCEPTED BY C <br /> ADDITIONAL 'COMMENTS: i <br /> DATE S <br /> PHASE II GROUT INSPECTION <br /> INSPECTION BY DATE PHASE II AL IN <br /> INSPECTION 'B <br /> H 1426 Rev. 12-77 � . <br />