Laserfiche WebLink
......_ .. ..•�.--rte a y <br /> E <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave,. , Stockton, CA 95205 Permit No. - at/ <br /> Telephone: (209) 466-6781 <br /> Date Issued <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> �7 <br /> This Permit Ex ires 1 Year From Date Issued � '�' . <br /> -2r 0ti SPCY-CCo p e In m 1 to Triplicate y� 73 <br /> P � � 1�-' <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 ! the q— <br /> Joaquin Local Hea�qh� <br /> District. q- N,+ <br /> ` SS Gr�CITY/TOWN <br /> EXACT STREET ADDRESS �l <br /> Owner's NamAak <br /> e*-&,/V% S -3 Phone <br /> Address 1V7 51;. City <br /> Contractor' s. Name'.` - Licensee Phone �� <br /> �. . i <br /> IS CERTIFICATE OF W0RKMNIV S CO!IPENSATiON INSURANCE ON FILE WITH SJLHD? YES <br />--TYRE OF- WORK-(Gheck) :- --NE-W W_EL-L-:Cl� -DEEPEN-Ci.-.-RECONDITION=C2-%- -DES-TRUCT1ON C 3 --- &- - <br /> WELL CIiLOfINATION 0 WELL ABANDONMENT 0 OTHERF-3 <br /> PUMP INSTALLATION.K . PUMP REPAIRED 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 <br /> —INTENDED USE TYPE OF-WEL-L _._ 'CON!STRUCf'ION SPECIFICATI09-S� Aq <br /> Industrial Cable Tool Dia. of Well Excavation. <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 /> eophysical Surface Seal Installed-b S <br /> t <br /> PUMP INSTALLATION: Contractor <br /> Type of PumpH.P. <br /> PUMP. REPLACEMENT: ❑ State Work Done: <br /> PUMP REPAIR: OState Work Done <br /> `DESTRUCTION OF WELL: - Well Diameter A proximate Depth <br /> Describe Material ana Proce ure V <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 /> CHealth 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 /> s 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. <br /> SIGNED EON <br /> LE: DATE: <br /> DR W PLOT PLTN REVERSE, IDE <br /> I FOR _DEP RT.. 1 USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE .� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPECTION <br /> TNSPECTION BY DATE INSPECTION BY DATE - 3 <br /> A/ � i� 1_L7 8 2M <br />