Laserfiche WebLink
"SAN MAQVIN .LUCAL HtAL I H UlJ I KIL I , <br /> OFFICEFOR USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. _y� cL <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued;>/-7 <br /> This Permit .Ex i res 1 ,Year .From bate 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 .descri.bed. This application is made in compliance with San <br /> Ioaqu.in County Ordinance No. 1862 and .the, Rules and Regulations of the San Joaquin Local Health <br /> District. 36 c . <br /> EXACT. STREET ADDRESS CITY/70WN <br /> owner's Name IZ4 Phone 6,C) <br /> 6,C) <br /> Address Ci ty ..�r <br /> Contractor' s NameLicense#3c��$�i�'� Phone % 6 72 / <br /> 'S CERTTrICATE 0 WORKMAN'S COMPENSATIO"I INSURAINCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION WELL ABANDONMENT ❑ OTHER (D <br /> PUMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT ❑ <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 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation . <br /> Domestic/privateDrilled_,„ __ Di-a. .-of. .We! 1__Casing <br /> r Domestic/public rDriven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary . Type of Grout <br /> f Disposal Other Other Information <br /> Geophysical 'I Surface Seal Installed by: <br /> - . <br /> C <br /> PUMP INSTALLATION: ontractor c <br /> Type of Pum . H.P. , <br /> PUMP REPLACEMENT: '] State Work Done '--, <br /> PUMP REPAIR: ❑State Work Done <br /> f F <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br />, <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 /> i Health District. Home owner or licensed agent' s signature .certifies the following: <br /> "I certify that in the performance of the work for whi-ch this permit is issued, I shall <br /> not employ any person in such manner as to become subj,ect .to Workman' s Compensation <br /> laws of California. " <br /> I WILL CAU--F—QR A GROUT. INSPECTION PRIOR TO GROUTING AND A- FINAL INSPECTION. <br /> SIGN D TITLE: DATE: a ��g <br /> 2 DR W PLOT L N ON REVERSE SIDE —� <br /> r <br /> FOR DEPARTMENT USE ONLY11 <br /> 1 PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION. PHASE III FINAL INSPECTION <br />' INSPECTION BY DATE INSPECTION BY DATE -. <br /> EH 1426 Rei_ 12-77 <br /> G1/78 2M <br />