Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> R OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.71 c1f <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued,�&.2 Ay <br /> This Permit Expires 1 Year From Date Issued <br /> Complete In Triplicate <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 /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. 1561W of /� PI ,16 <br /> EXACT STREET ADDRESS S ou7* ,L,9�/�CITY/TOWN Lrn A/ <br /> Owner's Name "'?% f� F_ALD_„p Phone <br /> Address 47:Z6'__ 1,411AIEP— a, Ci ty^, <br /> Contractor's Name x165,0 License#-3 3-7Vc'.P-hone 3 7_7 <br /> IS CERTIFICATE OF WORKMAN'S C0111PENSATIO'N INSURANCE ON FILE WITH SJLHD? YES 1_ — NI O <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN;4 RECONDITIONS DESTRUCTION C] <br /> WELL CHLORINATION 0 WELL ABANDONME T a OTHER <br /> PUMP INSTALLATION Q PUMP REPAIR O PUMP REPLACEMENT Q a <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY �- <br /> SEWAGE DISPOIELD —CESSPOOL/SEEPAGE PIT -----OTHER---- <br /> PROPERTY <br /> - OTHER-- <br /> PROPERTY LINE/1PRIVATE DOMESTIC WELL-4-522 PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> IndustrialX Cable Tool Dia. of Well Excavation 'Z.. <br /> _Domestic/private 7"Dri 11 ed Dia. of Well Casing e["603e 4 • T° We--_W, <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seals?sAtCa <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: []State Work Done - <br /> PUMP REPAIR: ❑State 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 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 California." <br /> I WILL CALL OR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: - 7-7 <br /> (DRAW PLOT PL N ON REVERSE SIDE <br /> FOR KPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 3� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> EH 1426 Rev. 12-77 1/78 2M <br />