Laserfiche WebLink
P 5AN JUAQUIN ,LUL AL .HtALI H Uli )I KIU <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Ex fres 1 Year From Date ,Issued 2 .. <br /> Complete In Triplicate <br /> Application is hereby made to the San Joaquin Local Health District for a 'pe.rmit- to construct <br /> and/orinstall the work herein described. This ,application is made in compliance with San <br /> ,'oaquin County Ordinance No. 1862 and the Rules and Regulations of. the San Joaquin Local Health <br /> w'strict. <br /> EXACT STREET ADDRESS CITY/TOWN <br /> Owner's Name Phone 142qlte')A —R <br /> Address. El 6ZCity <br /> Contractor' s Name 8,,-rj) i� e � ,$_S ,�� T 1� _ Li cense#,a qE pyq Phone L <br /> IS CERTIFICATE OF t4ORKt,Ail"'S"'CD".,PEt4SATIO"1 I"ZSURAINCE-ON-FIL'E WITH`-SJ!LHD?...' --Y-ES--Z-- -NO- - - i <br /> TYPE Or WORK (Check) : NEW WELL N DEEPEN [J �'� RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION [].,,,_WELL ABANDONMENT ❑ OTHER 0 - <br /> PUMP INSTALLATION)g PUMP REPAIR CI PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANKS SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELDaCESSPOOLJSEEPAG.E PITS OTHER <br /> PROPERTY LINE - PRIVATE DOM£STIC' WELL—:..� PUBLIC DOMESTIC 'WELL 0 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial � Cable Tool Dia. of Well Ex.cavation_1 <br /> ')<. Domestic/private Drilled Dia. of Well Casing =f <br /> Domestic/public Driven Gauge of Casing /;�t- <br /> Irrigation Gravel Pack Depth of Grout Sealer � f ! <br /> Cathodic Protection Rotary . `Type of Grout teem - <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: "f 77. <br /> � sr. f <br /> r t $ <br /> PUMP INSTALLATION: Contractor t <br /> Type of Pump �'- H.P. . <br /> PUMP REPLACEMENT: []State Work Done � `"` �` _- # ^# I <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth' <br /> Describe Material and Procedure r, _ <br /> I hereby certify that I have prepared this application and that the work willbe�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 or licensed agent' s signature certifies the following: <br /> "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 <br /> laws ' of California. " <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING ANDA FINAL INSPECTION. <br /> SIGNED ')'� TITLE: DATE: <br /> (DRAW PLOT PLTN ON REVERSE-SIDE) <br /> FOR DEPARTMENT USE ONLY <br />' PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II 16WT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY__- L/ DATE_ 6_-2 INSP.ECTION,.BY J ATE <br /> EH 1426 Rev. I2-77 - _ _ -- - <br /> - - - µ .1/78 2M <br />