Laserfiche WebLink
K±- <br /> f- SAN J0AQUI4,J_G,4L HEALTH DISTRICT - a <br /> f�OF ICE USE: 1601 E. Hazel ton`Ave. , Stockr ,�C-A 95205 Permit No. 79- ? <br /> Telephone: ,(209) 466-6781 -- <br /> APPLICATION FOR WELL INSTRUCTION OR PUMP PERMIT <br /> Date Issued- 1 -7 <br /> (Complete In Triplicate) <br /> Anplicatioh is herem <br /> by ade 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. f <br /> EXACT STREET ADDRESS ,� ;' , Lb lY 4 CITY TOWN P ' <br /> Owner's Name ,J i' Phone Q (qZ \� <br /> Address City <br /> ' Contractor' s Name f- S - .�E ,� ,� *License# Phone <br /> I5 CERTIFICATE OF WORKI1AN'S C0,11PENSATIO"1 IEISURA"10E ON, FILE WIfi1i SJLHD? Y YES NO <br /> TYPE .OF WORK (Check) : NEW WELD DEEPEN 3'- -RECONDITION Q DESTRUCTION❑ <br /> WELL CHLORINATION 0 ' WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATIONJ2 PUMP REPAIR❑ PUMP REPLACEMENT 0 � <br /> DISTANCE TO NEAREST: SEPTIC ,TANK SEWER LINES PIT PRIVY <br /> SEWAGE 'D'ISPOSAL FIELD iWoq) SSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE --PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL k <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation ' <br /> C�_Domestic/private Drilled Dia. of Well Casi.n�g h�� <br /> Domestic/public Driven Gauge of Casing ! e__ 101 <br /> Irrigation Gravel Pack Depth of Grout Seal So <br /> Cathodic Protection Rotary Type of Grout Z4 � <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor o <br /> Type of Pump — H.P. <br /> PUMP REPLACEMENT: FA State Work Done <br /> PUMP REPAIR: Q State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure � <br /> 'I hereby certify that I have prepared this application and that the work will be done in accordan(I <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 certify that in the performance of the work for which this permit is issued, I shall <br /> ' <br /> not employ any person in such manner as to become subject to Workman' s Compensation <br /> laws of California . " <br /> I WI CALL FOR A GRO IN TION PRIOR TO, GROU.TING AND FINAL INSPECTION. <br /> SIGNED TITLE: DATE: 11 <br /> DRAW PLOT PL N ON RE SIDE <br /> PHASE I FOR DEPARTMENT USE LY <br /> APPL I CATION, ACCEPTED BY s LV DATE -_— <br /> ADDITIONAL COMMENTS : - <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE – - INSPECTION BY.0 . ,,. DATE <br /> 1'1114-'26 Rev. 9/78 V 17117 °I - t�n��rwt co,Q9� 5/79 2M 0 <br />