Laserfiche WebLink
� r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 179- 761 <br /> Telephone: (0209) 466 -6781 <br /> APPLICATION FOR WELL "CONSTRUCTION OR; PUMP PERMIT Date Issued 117-9-7,9 <br /> This Permit Ex ires 1 Year From bate Issued <br /> Complete In Triplicate <br /> Application is hereby made to the San Joaquin Local Heal-th District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San <br /> County Ordinance 1,o. 1862 and thesRules and Regulations, of :the San. Joaquin Local Health -- <br /> District. <br /> ealth - <br /> Distr ct. <br /> EXACT STREET ADDRESS CITY/TOWN ,..�� <br /> Owner's Name Phoneme -- <br /> Address City i.. i <br /> Contractor's Name C° LicensePhone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIOIN INSURA*dCE ON .FILE VITH SJLHO? YES NO <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION�[3 DESTRUCTION❑ <br /> WELL CHLORINATION ❑ . WELL ABANDONMENT ❑ OTHER ❑ �+ <br /> PUMP INSTALLATION ❑ "PUMP REPAIR❑ PUMP REPLACEMENT ❑ F <br /> DISTANCE TO NEAREST: SEPTIC TANK EWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINEA& PRIVATE DOMESTIC WELL` PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL ; CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of: Well Excavation <br /> Domestic/private Drilled Dia. ofWell Casing 0 g- <br /> Domestic/public Driven .,.. Gauge of Casing /..I ' <br /> Irrigation Gravel Pack Depth of Grout Seal - ..` <br /> Cathodic Protection rRotary Type of; Grout F.< <br /> Disposal Other Other I;nformatio <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done s ler' <br /> PUMP REPAIR: ❑State Work Done <br /> DE5TRUCTION OF WELL: Well Diameter � " Approximate Depth <br /> `tf 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-X,Home owner-or-11 tensed agent' s signature certifies the following: <br /> "I certify that minthe- <br /> ,performance of the work for which this permit is issued, I shall <br /> not employ any personin such manner as to become subject to Workman' s Compensation c <br /> laws of California. <br /> I WILL CALL F R A . ROUT .INSPECTION PRIOR T GROUTING AND A FINAL INSPECTION. <br /> SIGNED fIgo <br /> TITLE: DATE <br /> .- D AW-PT-OT .-PLA"' ON REVERSE IDE <br /> FOR DEPARTME . USE ONLY., <br /> PHASE I rK . �. <br /> APPLICATION ACCEPTED-BY t . /LQ� "" ' L t DATE <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTIO -�` 1< 4 PHASE. III FINAL I PECTION nom` <br /> INSPECTION BY DATE INSPECTION BY = DATE - � '!r� <br />:.ru 1n9r- n,... 10 77 :� 7, /78 2M <br />