Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br />(FOR OFFICE USE: 1601 E. Hazelton Ave., Stockton, CA 95205 Permit No(79!!54Q <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued r29-79 . <br /> '(Eomplete In Triplicate): <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 Local Health <br /> District. <br /> EXACT STREET ADDRESS /A 4 CITY/TOWN <br /> Owner's Name Phone i� <br /> Address . .City.., . . . . <br /> Contractor's Name Li cense#,.f 5� Phone <br />.IS CERTIFICATE Of WORKMAN'S C01,1PENSATION INSURUIr N FILE WITH SJLHD? YES 0 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN RECONDITION [3 DESTRUCTION.[ ' <br /> WELL CHLOQ NATION L] WELL ABANDONMENT ® OTHER 0 <br /> PUMP INSTALLATION Q PUMP REPAIR 0 PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TAN SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL. IELR 15— CE P OL/SEEPAGE PIT OTHER <br /> PROPERTY LING (PRIVATE DOMESTIC WELD— PUBLIC DOMESTIC WELL -- <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ' <br /> Industrial Cable Tool Dia. of Well Excavation ._ <br /> Domestic/private Drilled Dia. of Well Casing .1 <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea ► <br /> Cathodic Protection Rotary Type of Grout <br /> 'Other Other Other Information -- <br /> Geophysicalt Surface Seal Insta ed b .� <br /> PUMP INSTALLATION: Contractor - r 6� <br /> Type of Pump H. <br />' PUMP REPLACEMENT: Q State Work Done <br /> PUMP REPAIR: QState Work ©one:, <br /> "^ . <br /> DESTRUCTION OF WELL: Well Diameter S'P� . dy-� Approximate, depth <br /> Describe MateFial and PrIocedure <br /> I hereby certify that I' have prepared this application and that the work will be done in accorda6'& <br />'with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin tocaI <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 shal l <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 GROUINFWtION PRIOR TO GROUTING AND A FINAL INSPECTION.' <br /> SIGNEDTITLE: DATE: <br /> —Mm PLOT PEW <br /> ON REVER SIDE) <br /> tF R MEN US ONLY <br /> 1PHASE I. <br /> (APPLICATION ACCEPTED BY Z DATE Z <br /> 1ADDITIONAL COMMENTS: <br /> PHASE I GRO INSPECTION V PHASE III "INAL INSPECTION <br /> ;INSPECTION BYG✓ DATE --ZI-791, INSPECTION BY dam' DATE r <br /> 17u 1A 9r De­ 0/70 /9%/ i 9 "1/h /78 2M <br />