Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> =. FFICESE: 1601 E. Hazel-tanbAve. , Stockton, CA 95205 [Permit No.Telephone: (209) A66-6781 <br /> APPLICATION FOR, WELL CONSTRUCTION- OR PUMP PERMIT e Issued,5-/o-79 <br /> (Complete In Triplicate) M i <br /> Application is hereby made to the San Joaquin Local� Health District for a permit to1-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 RegUl'ations of the San .Joaquin Local Health <br /> District. <br /> EXACT)STREET ADDRESS /If¢CkV11.[E ��/ �''p{�,E- ,�0,�(! �, �p ✓, CITY/TOWNCLk.;9Vk 1S <br /> Owner's Name J: Go, T Phone <br /> Address pp, ABOX- �8ro _ <br /> ty:raSlt�tfcTor,(/" <br /> Contractor's Name /boom Lf %merGcv/ �s License#P�', /6v� Phone_ /-6-371- S•z.� . <br /> c <br /> IS CERTIFICATE -OF. WORKMAN'S COMPENSATION INSURANCE ON. FILE WI.TH-SJLHD? YES N 0 <br /> TYPE -OF 'WORK "(Check) : NEW WELL DEEPEN ❑ - RECON DITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ -WELL ABANDONMENTIM OTHER f:3 ~� <br /> { PUMP INSTALLATION 0 rt PUMP REPAIREJ- PUMP REPLACEMENT []. <br /> f <br /> E . DISTANCE TO NEAREST: 'SEPTIC TANK SEWER LINES` PIT PRIVY R <br /> SEWAGE DISPOSAL IELD CESSPOOL/SEEPAGE PIT . OTHER..s ,"- ` m. <br /> PROPERTY LINE - PRIVATE DOffESTIC WELL.- -�.. PUBLIC D MESI'IC, WELL <br /> - INTENDED USE , TYPE OF-WELL..; CONSTRUCTION SPECIFICATIONS <br /> Industrial w Cable Tool ....Dia.- of-Well Excavation 3.�� Q <br /> Domestic/private __,Drilled Dia. of Well Casing <br /> Domestic/public <br /> on _Driven . Gauge of Casino <br /> Irrigation . Gravel Pack Depth of Grout'Sea <br /> _Cathodic Protection Rotary ' T _ <br /> _Disposai � a Other Type of Grout.. T. f'C. Cc�r�cr-e • - - " -t <br /> ___;.{_Geophysical M Other Information <br /> u Surface Seal Installed b <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. _ p. <br /> 'PUMP REPLACEMENT: 1 1 <br /> ❑State Work Done <br /> PUMP REPAIR:' ❑StaIte Work Done <br /> DESTRUCTIOW OF.WELL: Well Diameter` t q <br /> - Describe Materia and Procedure . 6 Approximate Depth �55i7'' <br /> i <br /> 1- hereby certify that I have prepared this application and that-theLL'work will be done in accordanci <br /> with 'San Joaquin' County Ordinances , State Laws , .and Rules_and 'Regul.ations..of .the San Joaquin-Local' <br /> Health .Di s trj ct. -.Home- owner or licensed agent' s s i'nature"certi f i es' the following <br /> "I 'certify that in the performance of the wor.k"'for-which this permit is is ued, `I shall" <br /> not mploy any person in such ;manner. as to become subject to Workman's Compensation <br /> laws.-of California, -- <br /> I WILL CAL A GROUT I SPECTION PR OR TO GROUTING ANDA -FINAL INSPECTION. . <br /> SIGNED TITLE: / f,(�r7 �•°� DATE: !O- 7,9 <br /> F D _L <br /> PHASE IFTR—DEPARTMENT USE ONLY <br /> APPLICATION _ACCEPTED 8Y DATE '��/0-7Y - , <br /> ADDITIONAL COMMENTS: <br /> PHASE Ii GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> EH 14 26 Rev. 9/78 ' <br /> 9/78 2M <br />