Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F�,F_FICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.7 2 <br /> Telephone: . (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 3�7 <br /> ('Comp 1 ete' I n Triplicate) �r <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 to -compliance with San . <br /> Joaquin. County Ordinance No. 1862rand .the Rules and Regulations of .the San Joaquin Local Health <br /> District. <br /> EXACT- STREET ADDRESS 4400 Waterloo'Road, Stockton' CITY/TOWN Stockton <br /> Owner's Name CHEVRON USA INC. - Phone 835-7637 <br /> Address 37 Banta Calif. 95304 - W <br /> .,,,_ _ City: -Bar�ta� <br /> Contractor's Name PARRISH INC. License# 100511 pho�ie --466-3831 <br /> IS CERTIFICATE OF WORKMAN'S"COMPENSATION INSURANCE ON FILE-WITH-S-J"LHD-? YES# . 0 <br /> TYPE OF WORK (Check) : N.EW ,WELL C� ID s <br /> ( 'RE ' <br /> DESTRUCTION Q <br /> WELL CHLORINATION'Q WELL ABANDONMENT {[ OTHER FJ <br /> PUMP INSTALLATION M PUMP.REPAIRL3. -'PUMP REPLACEMENT Q <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PZT`PRIVY _— <br /> SEWAGE DISPOSAL FIELD CESS"PUOL/SEEPAGE Pt�� OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL-. PUBLIC DOMESTIC WELL ` <br /> INTENDED USE TYPE OF..WEL.L... LL 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 ProtectionRotary Type of:Grout. <br /> Disposal Other Other Information <br />—Geophysical r - - Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor p '" <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑State Work Done _ ... <br /> PUMP REPAIR: C--]State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth QO' <br /> Describe MateriaT Materiaand Procedure fill with�beritoni.te'.arid ca off__. <br /> :ith- concrete. <br /> I hereby certify that I have <br /> prepared this Spplication and that- the work will be done in accordanci <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 WILE CAL FOR A GROUT INSP CTI,ON P <br /> ED IOR TO G TING­AND A FINAL INSPECTION. <br /> SIGN <br /> TITLE: President DATE: 5/3/79 <br /> R W PL T PL N REVERSE SIDE) . _. <br />'MASE I � � F R DEPARTMENT USE ONLY <br /> PPS LICATION ACCEPTED BYo-.- DATE �}r 79" <br /> WITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTT0 <br /> NSPECTION BY DATE INSPECTION BYI,,C�:" DATE . <br /> 7H 1 26 Rev'.- 9/78 <br /> W — 9/78 <br />