Laserfiche WebLink
SAN JOAQUIN LOCAL:,HEALTH DISTRICT <br /> EQR�FiCE USE: `� 1601 E. Hazelton Ave., .Stockton, CA 95205 Permit No. 7��3 <br /> Telephone: (209) 466 -6781-. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued , -7-71 <br /> f <br /> This Permit Ex i res .1 Year, From Date Issued S .12 c <br /> j Complete In Triplicate <br />' Application is hereby made to the San Joaquin Local 'Health District for armi <br /> pe t oc ristruct <br /> and/or install the work herein° described. This application is made i-n compliance with San <br />' ,oaauin County Ordinance No. 1862 and the Rules .and Regulations• of the San Joaquin. Local Health <br />, District. <br /> EXACT STREET ADDRESSP`7A '176 ' CITY/TOWN <br /> el J.-4&:a Z111 <br /> Owner' s Name r Phone Od 8= <br /> Address City <br /> Contractor' s Name �� License# Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE- WITH SJLHO? YES ?d0 <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION [] - DESTRUCTION <br /> WELL CHLORINATION ❑ WELLABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION ElPUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LI«NES'- PIT PRIVY `J <br /> SEWAGE`DISPOSAL FIELD : -CESSPOOL/SEEPAGE PIT OTHER � <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL J <br /> INTENDED USE TYPE OF WELL * ' CONSTRUCTION SPECIFICATIONS <br /> Industrial . Cable Tool Dia. of Well Excavation <br /> Domestic *^� . <br /> /Prvate ' - ' ,'�Drilled.• is Dia. of Well Casing .t., <br /> Domestic/public Driven Gauge of Casing ! <br /> Irrigation k Gravel Pack; Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> * Y .,, , yp cs� <br /> Disposal Other Other Information ,' <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: [3State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter l, ', Approximate Depth -7,7` ' <br /> Describe Materia and Procedure <br /> f <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: 4 <br /> "I certify that in the performance of the work for which this permit is issued, I shall k <br /> not employ any person in such manner as to become subject .to Workman's Compensation <br /> laws of California. " <br /> I WILL C L FOR A GROUT I S ECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE : DATE: <br /> DR W PL T PL N ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY i <br /> PHASE I <br /> APPLICATION ACCEPTED BY " � � <br /> DATE ,-3 -2 -!Z%;>' <br /> ADDITIONAL COMMENTS: 1 1 <br /> PHASE II GROUT INSPECTION PHASE IIIFINAL INSPECTION <br /> INSPECTION BY DATE_ _ /I/�/� INSPECTION BYA,1- DAT / 'E <br />_.H 1426 'Ri�d_ -12=77 <br />