Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.-Z9 /9A <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued -3,-/3-2 <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' Regdlations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS 0-7 fev f j Z�2 pzn ��ITY/TOWN_: 7Loc ft7rvy <br /> Owner's Name ? PhoneEf6Z- 78 <br /> Address Ci ty. 7': �-- <br /> e <br /> Contractor's Name R &- g Licensee Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURk*rJC ON FILE WITH-SJLHD? YES � 0 <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN ❑ ' RECONDITION ❑ DESTRUCTION[� � <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 0 <br /> PUMP INSTALLATION Lam- PUMP REPAIR 0- PUMP REPLACEMENT Q Vol <br /> DISTANCE TO NEAREST: SEPTIC TAN 5EWER LIMES - ' PIT PRIVY <br /> SEWAGE DISPAL � DA, CESSP L/SEEPAGE PIT— OTHER <br /> PROPERTY LINF� PRIVATE DOMESTIC WELL_ PUBLIC DOMESTIC WEFL— <br /> INTENDED USE TYPE OF WELL, CONSTRUCTION SPECIFICATIONS <br /> I{ <br /> Industrial Cable Tool Dia, of Well Excavation <br />-- ,Domestic/private Drilled Dia. of Well Casing f <br /> Domestic/public Driven Gauge of Casing -, <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout / <br />.Disposal Other Other Informat,aon <br /> Geophysical Surface Seal I'nsta��d ti <br /> PUMP INSTALLATION: Contractor-&-E a� R 5'4 k u �' <br /> Type of Pump o if <br /> / H.P. 2, <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: Q State Work Done <br /> DESTRUCTION OF WELL: ' Well Diameter Approximate Depth <br /> Describe Materia an roce ure <br /> I ,hereby certify that I have prepared this application and that the work will be donein accordance <br /> 4ith San Joaquin County Ordinances , State Laws , and Rules and. Regul-ations of the San Joaquin Local <br /> iealth 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 />[ WILL C LL FOR A G �UTINSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> iIGNED 00 <br /> TITLE: DATE: <br /> D W ;L N -ON -REVERSE-SIDE <br /> RP R ENT E ON Y <br />'RASE 1:' <br /> _ .. <br />,PPLI ATION ACCEPTED BY DATE <br /> iDDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III INAL INSPECTION <br /> NSPECTION BY DATE INSPECTION BY DATE <br /> H 14 26 Rev. 9/78 9/78 2M <br />