Laserfiche WebLink
f t <br /> SAN JOAQUIN,-LOCAL HEALTH DISTRICT <br />=W-�E <br /> SE: 1601 E. Hazelton Ave:, Stockton, CA 95205 Permit No. �� <br /> Tele.phone: (209) 466-6781 <br /> 5 <br /> APPLICATION FOR TELL CONSTRUCTION ORPUMPPERMIT Date Issued -7- <br /> This Permit Expires 1 Year From Date Issued <br /> Complete 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 CITY/TOWN S![�CX7W <br /> E Owner's Name �.p �'" "'' Phone yfl- 3�+6 uLr4KA <br />' Address2 Y L / <br /> ..k City. S__rn�.jt3 <br /> Contractor's Name �L t�..� � , ; C Li cense# -7(960Z- Phone <br /> s <br /> IS CERTIFICATE OF WORKMAN'S COMPENSA= i R fi10E ON FILE WITH SJLHD? YES NO <br /> j <br /> TYPE OF WORK (Chejck) : NEW WELLjo- DEQ # RECONDITION Q DESTRUCTION❑ i <br /> WELL CHLWINATION , WELL ABANDONMENT 0 OTHER <br /> PUMP INSTALLATION [j PUMP REPAIR❑: PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANKr SEWER LINES_ ' , PI�T,;P,RIVY, <br /> SEWAGE._DISP'OSAL FIELD-, -C.ESSPOOL/.S-EEP.AGE_P_I.T_w_--___ . "O_TH.ER <br /> PROPERTY LINES-.'- PA�IVATE ,DOMESTIC WELL PUBLIC DOMESTIC WELL ' <br /> INTEN r E . r <br /> TYPE OF WELL _ ;:� � CONSTRUCTION SPECIFICATIONS `I <br /> ustrial. Cable Tool Dia(-of*W 11i� Excavation J <br /> Domestic/p ivate Drilled Dia. of �Well Casing s <br />_ <br /> Do ibl-icy � flriven - � _ Gauge of Casing-� _ 11�It- <br /> Irri pati-on -- --_Gr- - ack :-- - Depth of- Grout Seal , - _ <br /> Cathodic; P�otection otary Type of Grout E� <br /> Disposals E Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION Contractor <br /> Type ofo Pump <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: .. QState Work Done rJ <br /> DESTRUCTION OF WE4L: Well Diameter <br /> Appioximate Depth <br /> er <br /> Describe Matia and Procedure _ , <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. IlHome owner or l-i c'i2�nsed agent"s? s'i gnature-certifies theufol lowing: <br /> "I certify thatiin the performance of the work for which this permit is'issued, I shall .A <br /> not employ any+ person in such manner as to become subject to Workman 's Compensation <br /> laws of California. " + -� p <br /> I WILL CALL FOR GR UT INSPECTION PRIOR TO GROUTING AICD-3A ,FfNAL,% SP'ECTION. <br /> SIGNED TITLE: DATEA_141L 7 7 <br /> R DR W PLOT PLVN ON REVERSSIDE) <br /> FOR DEPARTMENT- USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ,'/ 75' <br /> ADDITIONAL COMMENTS : <br /> PHASE !II ROUT INSPECTI N PHASE III FINAL INSPECTTO <br /> INSPECTION BY DATE INSPECTION BY \Zy _ DATE � <br />:1 1426 R,-v- 17_77 <br />