Laserfiche WebLink
a <br /> f <br /> SAN JOAQUIN LUGAL HtALIH UISIRICI <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone:, :`(209)- 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Ex ires .1 Year Fram 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 /> .'oaq , n County Ordinance ��o. 1862 and the` Rules and Regulations of. the San Joaquin Local Health <br /> J District. <br /> EXACT STREET ADDRESS CITY/TOWN )q <br /> Owner' s 'Name Phone ?Z 3 - 3 65 Y' <br /> Address 335' Aa-4 city y 111 ec;9 <br />' Contractor' s Name d-.S. License Phone - <br /> i r. <br /> 4 -IS-:'CERTYFI=CATE OF =WORKMAN''S'�COtIPENSATI'OII-T-fiSURAleiC£ ON-FILE-WITH'SJLiD?-"'`YES '"=' <br /> i - <br /> TYPE OF`WORK (Check) :' NEW WELL 0 DEEPEN [I ` RECONDITION 0-- DESTRUCTION[3-WELL CHLRINATION C3 WELL <br /> E OTHER 0 <br /> PUMP INSTALLATION 0 PUMP REPAIR❑ NT OMP REPLACEMENT <br /> k <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT. PRIVY <br /> SEWAGE{ PO <br /> DISSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> • R PROPERTY LINE -, PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> CX 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 /> DisposalOther - -- <br /> Other Information <br /> Geophysical Surface Seal Instilled—by: <br /> PUMP INSTALLATION: Contractor ,- —T <br /> Type of Pump e r e; H.P. j <br /> i <br /> PUMP REPLACEMENT: State Work Done / �f <br /> � .Sc.� 7�a �wJ�y.r•� <br />"PUMP"REPAIR-:' '""`—DState Work Done _.. <br /> DESTRUCTION OF WELL: Well Diameter """�"` <br /> _ Approximate Depth <br /> = -Describe Materfal 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 INSPECTION PRIOR TO GROUTING' AND A FINAL INSPECTION. p <br /> SIGNED z TITLE: DATE: (r" 96, / d <br /> ! <br /> (DRAW PLT PLAN ON REVERSE IDE <br /> i FOR DEPARTMENT USE ONLY <br /> PHASE I � <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: _-- <br /> PHASE II GROUT INSPECTION PHASE JIA FINAE INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DAT /0 <br /> EH 1426 Rev. 12=77 ®s 1 -70 Im <br />