Laserfiche WebLink
SAN J0AQUIN.,.1L0gAL,HEALTH DISTRICT <br /> OFFICE USE: 1601 E. Hazelton ,,eve. , :Stockton, CA 95205 Permit No.ZK,1"6 <br /> Telephoner (209) 466-6781 <br /> - r <br /> "APPLICATION FOR WELLCONSTRUCTION OR PUMP PERMIT Date Issued&/off <br /> This Permit Ex ires 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 2631 West State Route 12 CITY"/TOWN Lodi <br /> Owner's Name RICHARD TRAVERSO `—`" Phone <br /> Address 2003 Ladd Tract Road City Stockton <br /> Contractor' s Name Clark Well & Ecluipment Co. , IncLicense# 76602 Phone 462-597 <br /> F .. <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES X NO <br /> TYPE -OF WORK-(Check).: NE-W,WELLM- _ DEEPEN ❑ —-RECONDITION ❑. DESTRUCT ION,[j._ <br /> r WELC.CHLORINATION Q WELL ABANDONMENT 0 OTHER ri . <br /> PUMP INSTALLATION Q PUMP REPAIR 0 PUMP REPLACEMENT La <br /> DISTANCE TO-NEAREST; SEPTIC TANK SEWER LINES PIT PRIVY <br /> ; -- ' ` SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER . . <br /> PROPERTY LINE -, PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELLli <br /> f INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industri-a] Cable Tool Dia. of Well Excavation loll <br /> X Domestic/private -x .Dri.11-ed Dia. of Well Casing 6" <br /> Domestic/public � � Dri.iven Gauge of Casing &12 ' ► <br /> Irrigation Gravel Pack Depth of" Grout Seal 50' ' <br /> Cathodic Protection x Rotary Type of Grout t <br /> Disposal i Other Other Information t <br /> Geophysical ` Surface Seal Installed by: <br /> PUMP INSTALLAT}I'ON! Contractor ' <br /> Type of Pump H.P. <br /> PUMP' REPLACEMENT: [] State Work Done ' :a <br /> PUMP REPAIR: Q State Work Done <br /> DESTRUCTION OF WELL: Well Diameter- Approximate Depth <br /> Describe Materia an -Proce_ ure . .- ._..__:_ <br /> r <br /> I hereby certify that I have prepared this application and that the work will be done in` accordant <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 sh'aill <br /> not employ any person in such manner as to become subject to Workman's Compensation' ! <br /> laws of California." F <br /> I WILL CAL ' OR A GROUT INSPECTION PRIOR .TO GROUTING AND A FINAL INSPECTION. <br /> t SIGNEDTITLE: Owner DATE: 9/A/78 <br /> - - ` R.W.�PC T PL 'NON-REVERSE <br /> .. <br /> ' FOR DEPARTMENT USE ONLY <br /> PHASE I �}a M ` ' f, :> � ,;= ; ;:•..�`F <br /> ` APPLICATION ACCEPTED BY DATE__��-1 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> -.INSPECTION BY DATE INSPECTION BY C DATE_.5---/-.9—,77 <br /> ,7 <br /> 1426 Rev. 12-77 --1/78-;---. 2M. <br />