Laserfiche WebLink
441 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OR FF CE USE: ✓ 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.Z�_ `/� <br /> I Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT 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. <br /> EXACT STREET ADDRESS 412 Xv At+/a • off' s�lc ,/� dam', •/�° CITY/TOWN cf <br />. Owner's Name 14-1 Phone <br /> Addresse <br /> Ci ty, <br /> Contractor's Name �: Licensees9 a Phone -- � <br /> IS CERTIFICATE OF WORKMAN'S CO^4P SA IOP! INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : . NEW WELL 0 DEEPEN C7 RECONDITION Q DESTRUCTIONj� <br /> WELL CHLORINATION p WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION Q PUMP REPAIR[M PUMP REPLACEMENT C) <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSP L/SEEPAGE PI7_ OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC D MESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> X Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed y: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump_ -r-r,�r ,rt Q, H. '2- <br /> PUMP REPLACEMENT: M State Work Done ra.A( Y-.,w .Z'.�✓d d,�/ i��'" <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 accordanc <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 INSPE TIO P I TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED ITLE: DATE: ZA r_��e <br /> J�IJRAW_FLOT PLAN ON REVERSE-SIDE) <br /> FOR DEPARTMENT USE ONLY f <br /> PHASE I <br /> PPS LICATION ACCEPTED BY DATE .S <br /> ADDITIONAL COMMENTS: <br /> PHASE I GROUT INSPECTION7 PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE � <br /> EH 14 26 Rev. 9/78 8 2M <br />