Laserfiche WebLink
1ff-%,y0 VD1A C)o4c f16T1rV%— tee.!/ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT vjv� e1 tr° ed0 r%. <br /> fFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 79).3z�. <br /> Telephone: (209) 466-6781 A���y °E <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued , o- <br /> (Eomplete .'In Triplicate) <br /> j 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 with San ' <br /> Joagoin. County Ordinance No. 1862 and the Rules and- Regolations of the San Joaquin Local Health <br /> { District. ; <br /> a x <br /> ,-"EXACTSTREET ADDRESS CITY/TOWN_ <br /> F owner's Name 7L Phone Ci6I6911 <br /> Address_ a " �1s1bS Ci ty. - <br /> �Contractor's Name ��_ License#.P/y'79�� Phone <br /> IS CERTIFICATE -OF WORKMAN!,S COMPENSATION INSURANCE- ON LILE WITH-SJLHD? YES NO <br /> TYPE OF- WORK (Check) : NEW WELL❑ DEEPEN ❑ 'ADITJ,ONDESTRUCTION <br /> '`"--'`11WELL`CNLORINATI'ON Q WELD, rABAN' -'-MENTRD OTHER❑r <br /> ;.-�PUMPS-NSTAL'LATION ❑ P U M P-UMP REPLACEMENT.* <br /> DISTANCE TO NEAREST: ;SEPTIC TANK SEWf. ��' I _. .y PIT PRIVY <br /> SEWAGE',.aiSPOSAL 71 EL >' r CfSSPUOL/,SEEPAGE PIT OTHER <br /> d PROPERTY LINE -'F'�' -fE .r' ,,STIC W _+_ PUBLIC DOMESTIC WELL <br /> q r -rr <br /> - I.NTENDED 'USE TYPE OFA �- CONSTRUCTION SPECIFICATIONS _ <br /> Industrial D a. of Well Excavation c <br /> Domestic/private , ia. of Well Casing <br /> Domestic/public" .� Dr n,.f .Gauge of Casing <br /> Irrigation a�¢1\,kkDepth of Grout Sea <br /> Cathodic Prote an' . •; 'tar Type.of Grout <br /> Disposal '� ' `{ y iii✓ Other Information �' ? <br /> t Geophysical f r• Surface Seal Insta ed by: <br /> PUMP -INSTALLATION Con act .` <br /> T e of Pump K.P. <br /> PUMP REPLACEMENT: Q State Work Done <br /> ' PUMP REPAIR: ❑State Work Done v <br /> DESTRUCTION OF WELL: Well Diameter 6� . ' �', Approximate DepthQl <br /> Describe Material and Procedure-C.,& <br /> 7 <br /> I hereby certify thatI .have prepared this application and that,**the. work will be done in accordani <br /> with San Joaquin County Ordinances , State Laws , and Rules and Re ulations of the San Joaquin Luca' <br /> ' Health-District. Home.,own or licensed agent' s sigha tore certifll es the following: <br /> "I certify that in thejke 'emanceof-the work—i or, why ch thi-spermrt-i s- issued, I shall <br /> not employ any person iH such manner as to become ,subject,;._to workman's Compensation <br /> laws of alifornia:" y � <br /> I WILL C OR T T N PRIOR TO GROUTI'NG�'AIVD'A"FIN LSI' SPETION. <br /> SIG NE ` TITLE: rt DATE: 2 20`7 <br /> DR W PLOT PUTW ON REVERSE SIDE _ <br /> A' FOR DEPARTMENT USE ONLY ;A <br /> PHASE I <br /> APPLICATION ACCEPTED BY °6ATE ���?n1 <br /> ,ADDITIONAL COMMENTS: i — <br /> :v PHASE. II GROUT INSPECTION PHASE IISI FINAL INSPECTION <br /> INSPECTION BY'^ % _ DATE INSPECTION BY ' ' DATE — S`"'F� <br /> ,EH 14 26 Rev. 9/7E 9/78 M <br />