Laserfiche WebLink
SAN JOAQUIN, LOCAL HEALTH DISTRICT <br /> ffOROFFICE USE: 1601 E. Hazelton Ave. ,.1 <br /> CA 95205 Permit No. % 2� <br /> Telephone: . (209) 466-6. 781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT pate Issued G <br /> This Permit Expires 1 Year-From ;Date Issued, , <br /> Complete in Triplicate r' <br /> i' <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work hereiin 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—k(, 23 t( ' J' <br /> L44,� _99 CITY/TOWN :.z"z� <br /> Owner's Name ��_ qf �[ D �c � Phone �3-- <br /> Addressl � <br /> CityLt,.� �� . .. <br /> Contractor's Name License#3¢5—,yam Phone VV?-3 ,V6-S% T <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO'1 TINSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ N <br /> WELL CHLORINATION ❑ WELL ABANDONMENT Q OTHER 0 � <br /> PUMP INSTALLATION ' PUMP REPAIR❑ PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTICITANK SEWER LINES PIT PRIVY c <br /> SEWAGE.' DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER 5 <br /> PROPERTY LINE -, PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> _Domestic/privateMiJ Drilled Dia. of Well Casing <br /> Domestic/public ' Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor A/ <br /> Type of Pump H.P. `. <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: Q State Work Done <br /> 'DESTRUCTION OF­WELL, " `We1'l--D1-ameter = Approximate --Depth--wrt - <br /> Describe Material 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. 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 WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. 1 <br /> SIGNED TITLE: . .: . DATE: <br /> # DRAW PLOT PLAN ON REVERSES E - <br /> FOR DEP RTMENT USE ONLY <br /> PHASE I k <br /> r: <br /> APPLICATION ACCEPTED BY � P�- : `: DATE <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION. PHASE J11 FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> S <br /> 1:14 ,Q99. :....na,. ,'9-"77 `'�`� r 17Q 9M <br />