Laserfiche WebLink
t <br /> i <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br />__FOR OFFICE USE: 1601 E. Hazelton Ave. , Stodkton, CA 95205 Permit No. ,�'- q <br /> �? Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued to - <br /> This Permit Expires 1 Year .From Date Issued <br /> Complete In Triplicate <br /> Application is hereby made to the San. Joaquin Lodal 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 Re ulations of the4San Joaquin Local Health <br /> EXACT STREET ADDRESS, CITY/TOWN ' ' ' <br /> Owner's Name � � V1 Phone - ' <br /> Address ` `1 - .. y. - '" Cityar� " . .' * <br /> Contractor' s NameR/FJC� f 1At" j License#3�7,117'?Phone -' <br /> IS CERTIFICATE OF WORKMAN'S CO1iPENSATI0T1 I�JSURAINCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL�j DEEPEN ❑ `RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT a OTHER 0 <br /> PUMP INSTALLATION 0 PUMP REPAIR 0 PUMP REPLACEMENT Q <br /> DISTANCE TO NEAREST: SEPTIC TANK = '` SEWER LINES PIT PRIVY G <br /> SEWAGE DISPOSAL FIELD M CESSPOOL/SyPIT OTHER_ <br /> PROPERTY LINE `'PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> —D omestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal - <br /> Cathodic Protection Rotary Type of Grout- <br /> 5,0&-e-- '` 'ter �� ` ` <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor 1,05,rAl <br /> Type of Pump NF 5fV 'A'o H.P. <br /> PUMP REPLACEMENT: [] State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Proce ure <br /> 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. 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 G OUT IN$.P CT,ION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED �ti "i`�.iP !r ,' TITLE: .4;. � DATE:°`` <br /> DR W PLT L N ON REVERSE SIDE <br /> FOR DEP RTMENT USE ONLY <br /> PHASE I2"� <br /> APPLICATION ACCEPTED BY ',. �``� !' -- DATE ! ' <br /> ADDITIONAL COMMENTS: ' <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> - - - - - - <br /> 1 /-70 7m <br />