Laserfiche WebLink
--- - - - 7 <br /> SAN JOAQl��.N l��OCAL HEALTH DISTRICT <br /> EFFICE USf: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. ,y L,77 <br /> Telephone: (2O9} 466-67.8,1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued S-7 <br /> (Complete In Triplicate) , n � <br /> } J �! ? <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 herein described. This application' is made i-n 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 0 s- <br /> zaa CITY/TOWN <br /> _ c.¢�ary a <br /> Owner's Name ,� Phone <br /> .Address <br /> �S City <br /> Contractor's Name P.4,veg License# //Z Phonemay!- <br /> ?S CERTIFICATE OF WORKMAN'S C01,3PENSATIOM INSURA" E ON FILE WITH SJLHD? YES NO <br /> TYPE OF;WORK�(Check):NEW WELL DEEPEN ❑ RECONDITION [] DESTRUCTION[ v _ <br /> WELL CHLORINATION Q WELL ABANDONMENT Q OTHER ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT [] <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES. ;,. ' PI-T PRIVY <br /> SEWAGE DISPOSAdL� FIEL� CESSP L/SEEPAGE PIT /dam OTHER ` <br /> PROPERTY LING-fPRIV TE DOMESTIC, WELL� l PUBL C DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL �,. CONSTRUCTION SPECIFICATIONS <br /> Industrial _Cable Tool f . Dia. of Well Excavation <br /> Domestic/private Drilled `. Dia. of Well Casing •• <br /> Domestic/public Driven _. '` Gauge of Casing _ <br /> Gravel- Pack Depth -of Grout 'SeaUJ <br /> Cathodic- Protection Rotary Type.of.Grout - - -�� <br /> Disposal " Other <br /> Other ,Information <br /> -Geophysical Surface Seal Inst-TIed b <br /> PUMP INSTALLATION: `Contractor .: -- <br /> _ Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: C]State Work Done <br /> PUMP REPAIRi <br /> ❑State Work Done <br /> DE 11 <br /> WELL: ;, Well Diameter, . - - Approx'i'mate Depth - <br /> ` Describe Materia an roce ure <br /> I hereby certify.-•that-1--have-prepared -this-application-and-,that-the^work will be done in accordance, <br /> with San Joaquin County Ordinances , State Laws,';:and.-=RuI es ,.and Regulations. of the-San Joaquin Local <br /> Heal th-District.- - Home--oWher• or`l icen`sed agent's signature certifies the following: <br /> 1 "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.- '- iE <br /> laws of California. <br /> I WILL CA FOR A G OUT INS ION PRIOR TO GROUTING AND A 'FINAL INSPECTION. <br /> SIGNED <br /> TITLE: ,v DATE: 1 •Qa ..T� <br /> DR PL ON REVS S SIDE <br />?HASE I_ FOR DEPARTMENT USE ONLY <br /> RPLICATION ACCEPTED BY <br /> kDDITIONAL COMMENTS: DATE 3 .II-2 <br /> PHASE II GROUT INSPECTION PHASE III ;INAL I NSPECTION, <br /> NSPECTION BY DATES INSPECTION BY oW DATE/// <br /> 26 Re / ' �µ rte.- - r /-r-K-9A 7W ---9M } <br />