Laserfiche WebLink
' T SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONST4UCT't7N OR PUMP PERMIT Date Issued�� 7 <br /> (Complete In Tri pl i cate) <br /> 0 <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_ / CITY/TOWNfL— <br /> Owner's Name �c k rig u E sc <br /> Phone `' - f a <br /> Address �'dn� _ City <br /> Contractor's Nam e License#-?`J,?/0q Phone - ��'/L� <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCf ON FILE WITH SJLHD? YES <br /> TYPE OF WORK (Check) : NEW WELLi4 DEEPEN ❑ RECONDITION ❑ DESTRUCTION <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER - ----- `� <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT ❑ 9 <br /> 09 <br /> DISTANCE TO NEAREST: SEPTIC TANK/ > I JPIT PRIVY <br /> SEWER LINES � _ <br /> SEWAGE DISPOSAL IELD,/40 CES L/SEEPI GE PIT --= OTHER <br /> PROPERTY LINZO LI PRIVATE DOMESTIC WELL,,- PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of We 1 Excavation "' <br /> � <br /> Domestic/private Drilled Dia. of Well Casing Q _ <br /> Domestic/public Driven Gauge of Casing ,1 <br /> _Irrigation _Gravel Pack Depth of Grout Se ' <br /> Cathodic Protection _Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Insta e <br /> PUMP INSTALLATION: Contractor -t <br /> Type of Pump H• • <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 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 CAL OR A G UT INS E ION PRIOR TO GROUTING AND A'FINAL INSPECTION. <br /> SIGNEDTITLE: DATE: IV 22 <br /> 4223Z�-�-,e� <br /> 75 - 97LOT PLAN ON REVE SIDE <br /> R DEPARTMENT USE NL <br /> PHASE I <br /> PPS LICATION ACCEPTED BY DATE N 7?zow <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSP CTION <br /> INSPECTION BYE , :, ATE �_; INSPECTION BY DATE ���� �� <br /> g�78 <br /> EH 14 26 Rev. 9/78 M <br />