Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DI5TRICr <br /> FFICE USE: 1601 E. Hazelton�lVe..;-.Stockton, CA 95205 Permit No 2r l,;� 3 <br /> Telephon,e:_ . (209) , 466-6781' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued F-d3,79 <br /> This Permit Expires 1 Year. From' Date Issued <br /> Complete In Tr_ipl icate <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 in compliance with San <br /> ,'oanu�n County, Ordinance No. 1862 and •'the..Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS Q -v �P CITY/TOWN S�t ? 6J <br /> Owner's Name e, r`z z J 6 fu C. .S Phone_ j3/- z <br /> Address City <br /> Contractor' s Name u�a✓i'c �+ LL ! •'jv LicenseLZjS g'a& Phone <br /> I IS CERTIFICATE OF WOR01AN'S COMPENSATIO"J INSURA'MCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL— DEEPEN ❑ RECONDITION ❑ DESTRUCTION 0 <br /> WELL CHLORINATIQ WELL ABANDONMENT ❑ OTHER❑ <br /> - ON-�PUMP INSTALLATION: ❑ PUMP REPAIR❑ PUMP REPLACEMENT <br /> DISTANCE '1`0 NEARESST -S.Ekic TANK p6A�EWER LINES -PIT PRIVY. <br /> .­ ° SE AGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE..:-. PRIVArE DOMESTIC WELL PUBLIC DOMESTIC- WELL <br /> INTENDED USE "-` TYPEOF 'WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial . -Cable Tool Dia. of Well Excavation_ ix ' <br /> Domestic/private Drilled Dia. of Well Casingt- <br /> Domestic/public DriveA <br /> n Gauge of Casing /a GG -. <br /> Irrigation Gravel Pack Depth of Grout Seal o . <br /> Cathodic Protection Rotary Type of Grout (2 97M F AJ'r . <br /> Disposal Other. Other Information <br /> - :: Geophysical Surface Seal Installed b : <br /> w PUMP INSTALLATION: Contractor . Ld <br /> Type of Pump - <br /> H.P. <br /> " PUMP REPLACEMENT: ❑State Workrpone <br /> r <br /> PUMP .REPAIR: ❑State Work -Done <br /> DESTRUCTiON OF WELL: Well Diameter Approximate Depth" <br /> —Descrtb,e-Materia -an --Procedure <br /> I hereby: certify -that_ I have- prepared -this-.app,l i cati on- and that the work will be done in accordance <br /> with San Joaquin County.�Ordin•ances;, State Laws , and Rules and Regulations of the San. Joaquin LocaT' <br /> Health=District: " Home owner or Ticerlsed 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 AND A FINAL INSPECTION, <br /> SIGNED TITLE: �,,�.4� DATE: <br /> DRAW PLT PLN ON REVERSE IDE <br /> FOR DE ARTMENT USE ONLY <br /> PHASE I r <br /> APPLICATION ACCEPTED BY DATE E-1.2 3 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT 'INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY C- rj T_ DATE <br /> EH 1426 -Rev. 12-77 . 1 %74 IYKA � <br />