Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br />—FOR'-OFF ICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.-7 '7&/ <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued MAY 24 1978 <br /> This Permit Expires 1 Year From Date Issued <br /> Complete In Triplicate <br /> Application is hereby made to the San Joaquin Local Health °DJs'tY'fict,M- a permit to construct <br /> and/or install the work herein described. This aPpl-`cation is made in co iance with San <br /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San J quin Local Health <br /> District. 9a16 <br /> EXACT STREET ADDRESS 16&4 N--muse !a —A-sis,-, CITY/,`OWN <br /> Owner's Name "7 Q IM AO v Pha6e <br /> Address A.00 C i <br /> Contractor's Name— - Z-0 ..•> Li cense# 11'3 7it-J Phone ,6A 1- '7L 7A/- _ <br /> IS CERTIFICATE OF WORKMAN,S rn NS TI01 INSURANCE ON FILE WITH SJLHD. YES NO <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN ❑ RECONDITION Cj DESTRUCTION❑ <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION ❑ PUMP REPAIR 21 PUMP REPLACEMENT [I <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL_ PUBLIC DOMESTIC WELL o\ . <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ' <br /> Industrial Cable Tool Dia. of Well Excavation G <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> _Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor ' / grr - <br /> Type of Pump 0E4 1,tergo N.P. Via_ <br /> PUMP REPLACEMENT: ❑State Work Done ff <br /> PUMP REPAIR: [State Work Done cvmaf� .�5�� /4 Acta un snezr ©a•�.�1 <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 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 INSP 0 P 0 GROUTING AND A FINAL INSPECTION_. ,r <br /> SIGNED �G/ v ITLE: DATE: 14172 <br /> DR PLOT PLIM ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY / `�Y DATE 15i 31" <br /> ADDITIONAL COMMENTS: <br /> PHA II GROUT INSPECTION PHAS INAL INSPECTION <br /> INSPECTION B DATE INSPECTION BY DATE_5-�-76 <br /> EH 1426 Rev. 12-77 1/78- <br /> /78 2M <br />