Laserfiche WebLink
Am,4V SAN JOAQUIN 'LOCAL HEALTH DISTRICT <br /> UR ^FFICE US'E: 1601 E. Hazelton Ave. ; Stockton, CA 95205 Permit No. 7�,�_ <br /> Telephone: (209.-) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued &7g <br /> Thji s Permit Expires 1, Year From 'Date Issued <br /> Complete In Triplicate <br /> Application is hereby made tb 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 :3 <br /> Joaquin County .Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. 11 <br /> CoQ .L� . ,c.l-c.0 sic !_ s 1 tf5-- 23v <br /> EXACT STREET ADDRESS s"oa+ � ,� ¢� 6�J CITY/TOWN <br /> Owner's Name 'P�QPhone <br /> Address <br /> GitY <br /> 'Contractor' s Name y .,�. Li cense# !. s- Phone v ---76'x'.6 <br /> S <br /> I5 CERTIFICATE OF WORKMAN' COF�9P ATI ,"I INSURAINCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) :, NEW WELL 0 . DEEPEN ❑ RECONDITION C) DESTRUCTIONE] . <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 0 <br /> PUMP INSTALLATION ❑ PUMP REPAIR PUMP REPLACEMENT ❑ M <br /> DISTANCE TO NEAREST. SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE1DISPOSAL FIELD` CESSPOOL/SEEPAGE PIT _ OTHER <br /> PROPERTY LINE -.-PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS a w <br /> --Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing A- 1. <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout k, <br /> Disposal Other Other Information <br /> Geophysical Surface _Seal Installed by: Ao, <br /> PUMP INSTALLATION: Contractor —— 1 <br /> hg=e.- <br /> Type of Pump- ' H.P. a - <br /> PUMP REPLACEMENT: . []State Work Done <br /> PUMP REPAIR: [�IState-Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate depth <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordance <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local <br /> Health District. Home owner br licensed agent's signature certifies the following: <br /> "1 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 <br /> laws of California." <br /> j I WILL CALL FOR A GROUT INSPECTIO PR OR,.TQ GROUTING AND A FINAL INSPECTION. . <br /> SIGNED . LE: DATE: i <br /> Ia loor MAW PLOT PL ON REVERS SIDE <br /> FOR DEPARTMENT USE ONLY <br /> IIt PHASE I <br /> APPLICATION ACCEPTED BY nO ,,, �,, DATE LC117 IF <br /> ADDITIONAL COMMENTS: q <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> I� INSPECTION BY DATE INSPECTION BY ? DATE 10- 13-?,9 <br /> EH 1426 Rev.12=77 4 117 8 2M <br />