Laserfiche WebLink
r SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> �._`1i>>A-EF C liSE_ 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit .No.Z <br /> Telephone: (209) 466-6781 <br /> c — APPLICATION FOR WELL CONSTRUCTIO14 OR PUMP PERMIT Datee Issued, <br /> (Complete In Triplicate; <br /> } A-oplication is hereby made to the San Joaquin Local Health District.for a permit to-construct <br /> andlor instal', the work herein described. ' This application is made in compliance with San <br /> !oaquin .County Ordinance No. 1862 and the'Rules and Regulations of the San JoaquinLocal Health <br /> uistrict. <br /> F EXACT STREET ADDRESS 2— 7 CITY/TOWN S70CMA) <br /> Owner's Name P. .T N Ptiane �1 —/ <br /> a' Adaress PACcity S-60CM-J I <br /> E Contractor's Name WC(& icense#xPhone <br /> IS CERTIFICATE OF WORKIIANIS COMPE'tSATION INSURA"10E ON FILE WITH SJLHD? YES 11401 <br /> TYPE OF WORK (Check) : NEW WELL ER"- DEEPEN ❑ RECONDITION Q DESTRUCTION❑ <br /> - _— WELL CHLORINATION ❑ WELL ABANDONMENT O OTHER L] <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT [] ` 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK. rr SEWER NES�, PIT PRIVY ^ <br /> SEWAGE DISP SO AL f CESSPOOL/ £ C�£ ��" OTHER <br /> z; PROPERTY L?Nr&7PRIVATIELDfi ESTIC WEL PUBLIC DOMESTIC WE" L�� <br /> INTENf?cD USE -TYPE OF WELL CONSTRUCTION SPEGIz=ICATiONS . : <br /> r' ndustrial Cable :Tool Dia. of Well Excavation /0 <br /> �Domestic/private Drilled ' Dia. of Well Casing <br /> ' Domestic/public Driven Gauge of Casing. P P <br /> r' Irrigation avel Pack Depth of Grout Seal <br /> Cathodic Protection �Rotary . Type of Grout i3I ZZI <br /> Disposal Other . Other. Information <br /> Geophysical Surface Seal Insta e <br /> PUMP INSTALLATION: Contractor -TRT ANLL &WfiP <br /> Type of Pump H.P. - <br /> PUMP <br /> , . -PUMP REPLACEMENT: ,--]State Work Done <br /> P` REPAIR: OState Work Done <br /> 1)ESTR1_1r.7 '[ N OF WELL: 'yell Diameter Approxi ate Depth <br /> y w Describe Material and Procedure ; <br /> f I hereby certify that I have prepared this application and that the work will be' done -in accord3 <br /> rri�'n Sari Joaquin County Ordinances, State Laws, and Rules. and Regulations of the San Joaquin Loc; <br /> 1'•istrict. Howe owneror licensed' agent's signature certifies the following: <br /> certify that in• the performance of the work for which this permit is °issued,, ' I shall i <br /> noc ennp'luy any c}erson in such manner as to become subject to ,Workman's;.Compensaticn <br /> g� 1:iws of California." <br /> I _CCAI-LLFOR A GRCV0'T INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. . <br /> TITLEDATE: G=a�-75 <br /> (DRAW PLU 79 ON 'REVERSE SIDE) W� <br /> R DEPARTMENT USE ONLY <br /> r:C;-1,1 F 1.0'G y ATE --2 <br /> la�r PHAS II NAL IWUIJON . S <br /> DATE • INSPECTION <br /> T �: <br />