Laserfiche WebLink
f y SAN JOAQUIN LOCAL HEALTH DISTRICT F. <br /> _FORS OF ;,ICE USE: 1601 E. .;Hazeltdn Ave. , Stockton, CA 95205 Permit No. 7 9- 9.51 <br /> Tel ephone: °.(209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued - <br /> (Complete In Triplicate) I - 9-_f� <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct ; <br /> and/or instal '; the work herein described. This application is made in compliance with San <br /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. �r`-4cv7_A_t 2 -030-q0 J <br /> EXACT STREET ADDRESS 1V CITY/TOWN <br /> Owner's Name -m`a/4" ram Phone <br /> Address 4 e JV 4,6 4�7 s City <br /> Contractor' s Name License# tf,3 91d-_-Phone G — 7 7-4 <br /> IS CERTIFICATE CF 140RK",A14'S CO}1PENSA I0"J I'35URA�lCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF. WORK (Check) : NEW WELL 0 DEEPEN CD. RECONDITION ❑ DESTRUCTION❑ � ' <br /> WELL CHLORINATION p WELL ABANDONMENT ED OTHER 0 o <br /> PUMP INSTALLATION Dfl PUMP REPAIR 0 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 /> X Domestic/-private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal i <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal N7 Other, Other Information <br /> Geophysical Surface Seal Instal b : . .� <br /> PUMP INSTALLATION: . ,, Contractor a-�. <br /> Type of Pump uZ6 H.P. <br /> PUMP REPLACEMENT: , 7IState Work Done + <br /> PUMP _: C]State Work Done b <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedgre <br /> I hereby certify1that I have prepared this application and that the work will be done in accordant <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 INSP rCTI P i TO GROUTING AND A FINAL INSPECTION. <br /> SIGNE ITLE: .'-�� DATE:__�A ;0 L, <br /> DR W PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I r+�c1✓ <br /> APPLICATION ACCEPTED BY DA E 2� <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROU INSPECTION I PHASE III FINAL INSPECTION <br /> INSPECTION BY ATE INSPECTION BY DATE. 7- <br /> s:14 1A 9r, Rani G/7Q -- 5/79 2M <br />