Laserfiche WebLink
JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 9�165 Permit No.79-ao tr <br /> Telephone: (209) 466-6781 <br /> Date Issued 3/3-79 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit Expires 1 Year From Date Issued <br /> Complete In Triplicate <br /> )lication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> • /or install the work herein described. This application is made in compliance with San <br /> 3nuin County Ordinance ":o. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> strict. <br /> ACT STREET AD 55 I/ CITY/TOWNOo"'_" r 611 <br /> ner's Names _ Phone <br /> dress CityJ� }�'d� <br /> ntractor's Name License#/) a,-7373 Phone Z7,1 <br /> CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES 1/ NO <br /> PE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ �� <br /> WELL CHLORINATION 0 WELL ABANDONMENT ❑ OTHER ,Fa <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACE NT <br /> STANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL d� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing_ <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed b : <br /> 1MP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> 1MP REPLACEMENT: [] State Work Done <br /> JMP REPAIR: GState Work DoG% J/ ' f 7 <br /> STRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> hereby certify that I have prepared this application and that the work will be done in accordan <br /> ith San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Loca <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 <br /> laws of California." <br /> WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> IGNEDI Cl TITLE:�� DATE: 3.9- �9 <br /> DR W PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> RASE I DATE <br /> PPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> NSPECTION BYDATE INSPECTION BY DATE v-? <br /> Wi, /7 Q 9 <br />