Laserfiche WebLink
E i <br /> I SAN JOAQUIN•LOCAL HEALTH DISTRICT <br /> OR OFFICE USE: 1601 E. Hazelton Ave, , Stockton, CA 95205 Permit No. `7 <br /> Telephone: (209). 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION QR PUMP PERMIT Date Issued is -7 <br /> Thins Permit £x�ires 1 }Year.From Date Issued <br /> -�- Comp .6te I n rip i Cate t)09— C50-03 <br /> �;'f�;l.�r_.�E.:.:��,��y� •�3 • <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 Lodal Health � <br /> District. ie• <br /> EXACt STREET ADDRESS oo' CITY/TOWN ~ <br /> Owner's Name E D UGC Phone] 1,Ij <br /> �--�-- <br /> Address 6_3S Ci ty-&aY45L , <br /> G <br /> Contractor's Name Ql i cense#33 70 -Rhone -3 37 <br /> IS CERTIFICATE OF WORKMAN'S COIMPENSATIOtI INSURAINCE ON FILE WITH SJLHO? YES NO <br /> *.T'YPE 0F=WORK"6(-Ch6Ck) : -NEW-WECto- '-DEEPEN-r-"- - tCON'DITION-0 <br /> WELL CHLORINATION Q WEI:L ABANDONMENT Q OTHER 0 - ::4 <br /> PUMP.. INSTALLATION Q PUMPrREPAIR❑ PUMP REPLACEMENT 0 <br /> DISTANCE TO NEARES-L:- SEPTIt TANK/M/ SEWER `LIkS PIT PRIVY4 <br /> MSEWA61* DISPOSAL F ELD t Y.CESSPOOL/SEEPAGE PTT OTHER N ,j <br /> ^. PROPERTY LINE -, PRIVATE DOMESTIC WELL PUBLIC DTO ESTIC_ E4�'LL f <br /> INTENDED USE �YP1r`0'F kLL�» CONSTRUCTIOW SPECIFICATIONS <br /> In ustrial ' Cable Tool s Dia. of Will Excavation �i577A16' <br /> �Z, !�:Dr <br /> astic/private illed ,1 Dia. of Well Casings : axe; `� .��� <br /> '. a _ of7a_sa ng . 7.0 <br /> -- - ,—r <br /> R-irrigaV-6n "� Travel Fags Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information W14e,lvs7W.'_ f to <br /> Geophysical _ Surface Seal Insta ed y:^ 7,A76K-• <br /> PUMP .INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: ❑State Work Done _ __7, <br /> DESTRUCT-1ON_OF_WELL--_ __Ap.proxi.mate_Depth <br /> Describe Materia an rote ure ; <br /> 4 I hereby certify that I have prepared this 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. Hoine, owner or licensed agent's signature certifies the following: i <br /> "I certify that ii� he performance of the work. for which this permit is issued, I sha-1-1 <br /> not employ any pe son in such manner as to become subject to Workman's. Compensation 1` <br /> laws of California. 4'd <br /> I WILL CAL , FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: 3 7 9 <br /> PLOT PLAN ON REVERSE SIDE) <br /> PHASE I R DE R N USE ONLY <br /> ' <br /> TP—PLICATION ACCEPTE9AY DATE /d/4,- I <br /> ADDITIONAL COMMENT5:. E F . <br /> PRASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> 4 INSPECTION .BY DATE INSPECTION B DATE <br /> EH 1426 -Rev: 12=71 <br /> M <br />