Laserfiche WebLink
SAN JOAQUINPLOOALc-UE;ALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton.°Meo; S{tICRton, CA 95205 Permit No. <br /> Telephoners ('209) 4.66_ :781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT L Date Issued - <br /> Th7.s; Pe.rmlt �E, kr,,,esfa °:Year,. Frp t I a <br /> jn, D .e slued y. <br /> 's i!,? <br /> g1�p7ele :Ira;.I;r1Apl;icate _,E r ,- <br /> App' kation is hereby made to the San Joaqui`ii `Lc1 =He'aTt 'Di� tnict for afi pert= a`°eonstruc't` <br /> and/ar {n'staTl'�`t`f ` wo'►�k 'HerPh de rr 6e This wC'V" icAL~-f �r s, made,=ir:1-,Lt �ipl ianc�e w%th San <br /> �oan:>>n f o�rn` f r i4� nc `pro: 18 2=`Amd the-RbTl 1s Regtplat4on5 of tfie.;�Sr&mAoaquili'-� wocal+..Hoajth <br /> C'�Strct. <br /> EXACT <br /> ATR <br /> E E l D RrS.S} <br /> 4 S G W/CCITY/7011� <br /> Owner's Name <br /> Phone <br /> Ad d;nn's s <br /> _.._.... .. _.... . y= /36 <br /> Contractor's Name License <br /> � Phone II <br /> IS CERTIFICATE gF WORKMAN'S COtiPENSATIO"J INSURANCE O-N FILE. WITH SJLHD? <br /> TYPE OF WORK (Check) : NEW WELL O DEEPEN O' RECONDITION,0 DESTRUCTION ED <br /> WELL CHLORINATION 0 WELL ABANDONMrNT 0 OTHER 0 ' � <br /> PUMP' INSTALLATION O PUMP. REPAIR O PUMP REPLACEMENT ❑ o <br /> DI.STANCE, TO. NEAREST: SEPTIC TANK SEWER LINES; PIT PRIVY <br /> SEWAGE. DISPOSAL FIELD,. . CFSSPOOI./SEEPAGE PiT. . OTHER <br /> PROPERTY LINE . -. PRIMATE DOMESTIC WEL PUBLIC DOMESTIC WELL '- <br /> INTENDED USE ' <br /> TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ' Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled' : Dia. of Well Casing <br /> Domestic/PubTi,c Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed b <br />'UMP INSTALLATION. Contractor I <br /> Type of Pump M.P. <br />'UMP REPLACEMENT: State Work Done <br /> UMP REPAIR: O State Work Done <br /> ESTRUCTION OF WELL: . Well Diameter <br /> Describe Materia an' Procedure Approximate Depth <br /> hereby certify that I have prepared this application andthatthe work wi-ll be done in accordance <br /> ith San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local <br />?alth District. :Home owner or' licensed agent' s sighature '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 mariner•. as� to� become subjects Com' <br /> to Workman' Cpensation <br /> Taws of Cal i-fornia. "' <br /> WILL CALL ,FORA ;G.ROUT .,INSPECT I.OfV .PRIOR!..TO .GROUTING ,ASVD A ;FI,NAL INSPECTION <br /> GNED TITLE: C� DATE: <br /> DRAW PLOT PL N ON REVERSES <br /> FOR DEPART <br /> EAS E I SE ONLY <br />'PLICATION ACCEPTED Y DATE: 4 <br /> MDITIONAL COMMENTS: <br /> PHASE, II ; GROUT 'INSPECTION = PHASE III: FINAL: YA <br /> CTION <br /> 5PECTION BY DATE <br /> 'INSPECTION BY <br /> a <br />