Laserfiche WebLink
SAN JOAQU,IN LOCAL HEALTH DISTRICT � Permit Na. <br /> FFICE USE: 1601 E. Hazel ton,. Ave. ,_:Sto466 6, GA 95205 <br /> ! Telephone: (209) 466-6781 pate Issuedi_zs��I_ e <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit.; Ex ires 1 Year From Date issued ; <br /> ! Complete In Triplicate <br /> made to the San Joaquin. Loca1 Health District <br /> inrcompliance ermit <br /> Application is hereby liancetwith nSan <br /> uct <br /> lication is made p <br /> and/or install the work- herein described. : This .app <br /> County Ordinance No. <br /> 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> ,,oaqu n Co y ' <br /> District. " CITY/TOWN <br /> EXACT STREET ADDRESS Phone i <br /> Owner' s Name City <br /> Addressicense# i Phone y� <br /> Contractor' s Name <br /> is CERTIFICATE OF WORKMAN'S COMPENSATION IPSSURA"aCE 01 FILE WITH SJLHD? YES <br /> ----- .� <br /> _ DESTRUCTION[� <br /> ' DEEPEN [J RECONDITION Q <br /> TYPE OF WORK (Check) : NEW TELL C WELL ABANDONMENT L7 OTHERIii B` <br /> WELL CHLORINATION Q PUMP REPLACEMENT 0 � <br /> PUMP INSTALLATION M PUMP REPAIR� <br /> DISTANCE TO NEAREST: SEPTIC TANKy��[.SEWER LINES ¢/ <br /> IT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PI�T OTHER 3 <br /> PUBLIC DOMESTIC WE�— <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL------- _ } <br /> INTENDED USE TYPE OF WELL <br /> CONSTRUCTI60N SPECIFICATIONS <br /> Cable Tool Dia. of Well Excavation `T <br /> Industrial Drilled Dia. of Well Casing ' <br /> Domestic/private ° <br /> Driven - Gauge of Casing 3 - , <br /> 1 ,, Domestic/public Depth of Grout Sea ;i <br /> I —Irrigation Gravel Pack <br /> Cathodic Protection Rotary Type of Grout ! t `� <br /> Disposal Other_ Other Informations 4 <br /> ! i Surface Seal instal1ed: b <br /> —Geophysical <br /> « PUMP INSTALLATION: Contractor <br /> -- TYpelof Pump r e <br /> Q State Work Done <br /> PUMP REPLACEMENT: � <br /> PUMP REPAIR: estate Work Done :. I <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> drdI have re <br /> pared this application and-that the work will Sandon <br /> in acc an <br /> tate <br /> I hereby certify that p State Laws , and Rules and Regulations of t <br /> with San Joaquin County Ordinances, <br /> Health District. Home owner or l� sof ted henworksforature whichcth sfpermitthe <br /> isfollowing: <br /> issued, I shall <br /> 4 "I certify that in the performance <br /> not employ any person in such manner as to become subject to Workman's Compensation ` <br /> I laws of California." Jr <br /> � I WILL CALL FOR A G UT INSP TION RIOR TO GROUTING AND A FINAL INSPECTION. DATE: -- <br /> ' SIGNE TITLE: <br /> f <br /> DR <br /> PL T PL N ON REV RSE <br /> ;- - -s- --"FOR DEPARTMENT USE ONLY <br /> , PHASE i F $ DAT£ � . <br /> APPLICATION ACCEPTED RY <br /> ADDITIONAL"COMMENTS "` ';��t.. �.., PHASE=I`I"I AL-IN PECTION- <br /> L �� . �:PHASE. I..I-GROUT INSPECTION 8 INSPECTION BY ATE <br /> `INSPECTION. BYE, _ .-# ;.t DAT Z_'ai✓ <br /> T '78 Z <br /> - - �- Kn -7 <br />