Laserfiche WebLink
SAN JOAQUIN• LOCAL• HEALTH DISTRICT <br /> FI E: 1601 1 lazelton' Ave. ,. StockTM ,,-CA• ! )5 Permit No. 79- 2/3 <br /> Tel-ephone: (2019) 406-6781- , <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 3-/3-�9-�9 <br /> This 'Permit- Ex ires I Year` 46m Date Issued <br /> Comp ete m Triplicate) <br /> .i <br />.pplication is hereby made "to the San Joaquin Local Health, Distrie$ for a permit to construct <br /> nd/or install the work herein described. This application is made in compliance with San <br /> oaouin County Ordinance No. 1869 and. the Rules and Regulations of the San Joaquin Local Health <br /> istrict. <br /> XACT STREET ADDRESS Vt' ti CITY/TOWN + <br />-wner' s Name A14-� Phone <br /> ddress f City <br /> ontractor's Name 2 License#,q9l1 Phone a2— /0,/ <br /> S CERTIFICATE OF WORKMAN'S COMP RATION INSURANCE ON FILE WITH SJLHD? YES NO <br /> YPE OF WORK (Check) : NEW WELL L 111� DEEPEN p RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER 0 gJ <br /> PUMP INSTALLATION 0 PUMP REPAIR 0. PUMP REPLACEMENT ❑ �p <br /> ISTANCE TO NEAREST:' SEPTIC TANK SEWER .LINES PIT PRIVY <br /> SEWAGE OISPOS L FIELD ES <br /> CSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE =. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WE4L CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia: of Well Excavation <br />� Omestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven - Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea n <br /> Cathodic Protection. Mary Type of Grout' no i <br /> Disposal TOther Other Information — 2 <br />_Geophysical } Surface Seal Insta e b <br /> JMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br />)MP REPLACEMENT: 0 State Work Done <br /> JMP REPAIR: ❑State .Work Done <br /> STRUCTION OF WELL: Well, Diameter Approximate Depth <br /> Describe Materia' and Procedure <br /> hereby certify that I have prepared this application and that the work will be done in accordance <br /> dth San Joaquin County Ordinances, State Laws ; and Rules and Regulations of the San Joaquin Local <br /> aalth 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 ny .pe so in such manner�as' to become subject to Workman"'s Compensation <br /> ws of Cal forni . <br />_ L CALL FO G TP C I TO GROUTING ANDA INAL INSPECTION. <br /> �z_ <br /> GNED , �, TITLE, p DATl /— <br /> DR PLT EAN ON REVERSE SIDE)R <br /> F L�DEP RTMENT <br /> USE ONLY ' <br /> BASE I <br />'PLICITTION ACCEPTED, BY DATE — <br />�IDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> SPECTION BY DATE INSPECTION BY �,,JJ,, DATE % %,2s_ 7p <br /> i <br /> 1 AOC n_.. ,n -ro , 71' n... <br />