Laserfiche WebLink
fry �� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT S. i,4 <br /> FFICUE USE: 1601 E. Hazelton Ave. ,,yStockton, CA 95205 Permit No. (>3 <br /> p Telephone " ' 209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued /- <br /> (Complete In Triplicate). M <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 i.s 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 31 CITY/TOWN 4Sock�nAJ <br /> Owner's Name ,�1; <br /> ,moi Phone Ell-- o H 7 2: <br /> Address / .�' I r✓ 44.1 <br /> CityS G/C ; <br /> Contractor's Na'me-A9&/&/,o v1 lcL1,,u 'cense 3Vg/' 3 Phone .3b8 l 7c <br /> IS CERTIFICATE ,OF WORKMAN'S .COMPENSATION INSURANCE ON FILE WITH SJLHD? YES O j <br /> TYPE OF WORK (Check) : NEW WELLZ DEEPEN ❑ RECONDITION ❑ DESTRUCTION d <br /> WELL CHLORINATION ❑ WELL ABANDONMENT C7 OTHER <br /> ' I F PUMP INSTAL LAT I OIV.X—PUMP .REP_AI.R.❑—P-UMP-R"EPLACEMENT ❑ :- <br /> DISTANCE TO NEAREST' 'YSSEPTIC TANK eDl r SEWER111NES 7.S"/ 'SPIT PRIVY 6� ; 4 <br /> SEWAGE DISPOSAL FIELD ©A/ CESSCOL/SEEPAGE PlTiyati.ra OTHER <br /> PROPERTY SINE - ,PRIVATE 'DOMESTIC WELL ZAL PUBLIC DOMESTIC ELL <br /> INTENDED_USE ' * <br /> SE , * � � � -1� <br /> 1 TYPE F. WELL �,''� CONSTRUCTION 'SPECIFICATIONS .. . <br /> Industrial Cable-Tool : Dia. of We Excavation r,2 " <br />=Domesti"c/private Ori I9-e'dr# �; - -Dia. of Well Casings '� - <br /> Domestic/public Driven ,,; Gauge of Casing =,r ez <br /> Irrigation Gravel Pack'"""'"� Depth of Grout Sea . r <br /> Cathodic Protection Rotary T - .e of Grout �. <br /> Disposal Other Other Information <br /> Geophysical <br /> Surface Seal Insta edJ�II-L A 1t. <br /> PUMP INSTALLATION: Contractor lfQ�k�ovjc ,I'LL- XI J-L- r n9 G z{lay <br /> Type of Pump a ,-r, a ¢ r- <br /> PUMP REPLACEMENT: Q State Work Done <br /> PUMP REPAIR: ❑State Work Done $ <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> .F Describe Mate-r-11-al .,and Procedure <br /> I hereby certify that I have prepared thRi's application and that the work will be done in accordance' <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 /> 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 /> r <br /> SIGNED D L` ONTRE: SID �� DATE: _ /�-7 <br /> I <br /> FOV/DEPAR7ENT USE ONLY <br /> PHASE I ,..,� <br /> APPLICATION ACCEPTED BY _ -�DATE;S- <br /> ADDITIONAL COMMENTS:=. -�, <br /> _. <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECT N <br /> INSPECTION BY DATE `INSPECTION BY DATE <br />.H�11'4 26 Rev. 9/78 9/78' 1 2M •, <br />