Laserfiche WebLink
./L)6& -sr 7V Z&VHazeltoD <br /> SAN JQAQUI OCAL HEALTH DISTRICT <br /> Stockton, CA 95205 Permit No. 2,XO'� <br /> Fog FFICE USE: 1601 E. Telephone:Ve(209) 466-6781 <br /> Date Issued <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit Ex ires 1 Year From Date Issued- <br /> Complete In Tripl<ica e <br /> Application is hereby made to the San Joaquin Local Health District forcamplince <br /> mit <br /> twithn5ahuct <br /> and/qr install the work herein described. This application is made in p. <br /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> n15tr.iC:t. <br /> 'S I /{�, CITY/TQ N E <br /> FS <br /> EXACT STREET 'ADDRES l r ZX � R <br /> Owner-,' s Name IC - <br /> Phone <br /> Ci ty <br /> ::: <br /> Address oc 'f <br /> Contractor' s Name <br /> License Phone <br /> I5 CERTIFICATE OF WORKMAN'S C0111PENSATIO�! INSURANCL ON FILE�IITII SJLHD? YES X10 <br /> _ s <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN 0 RECONDITION ED DESTRUCTION(2 <br /> WELL CHL RINATION Q WELL ABANDONMENT 0 OTHER 0 T � <br /> PUMP INSTALLATION E3 P_l_!MP REPAIR 0PUMP REPLACEMENT L� <br /> DISTANCE TO NEAREST: SEPTIC''TANK4 7� SEWER LINES PIT PRIVY <br /> S CESSPOOL/SEEPAGE PIT /�— -It OTHER <br /> SEWAGE DISPOSAL FIELD <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL . PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL <br /> CONSTRUCTION SPECIFICATIONS ' <br /> Industrial Cable Tool Dia. of Well Excavation 7- <br />;Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing o - <br /> t Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout <br /> ► Disposal Other Other Information <br /> Geophysical Surface Seal Instal ed by: <br /> `. PUMP INSTALLATION: Contractor H.P. <br /> Type of Pump <br /> JPUMP' REPLACEMENT: [nState Work Done { <br /> PUMP REPAIR: QState Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materia and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done i-n accordant <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 ali rni ." <br /> � I WILL CA 0 G UT IN P TION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED <br /> TITLE: DATE: <br /> DR W PL T ' L N ON REVERSE SIDE <br /> I FOR DEPARTMENT USE ONLY <br /> PHASE I DATE 7 l <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE � I�NS .PHA E II GR UT INSPECTION Z <br /> INSPECTION QY DATE 7 j� 'l8 INSPECTION BY <br /> 1178 2M <br />