Laserfiche WebLink
l <br /> SAN 1QUIN LOCAL HEALTH DISTRICT <br /> 2 )FFI'� USE: 1601 E. Felton Ave. , Stockton, CA 9520 Permit No._j' <br /> Telephone: (209) 466-6781 <br /> - =-- 1 APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued? -/3-29 <br /> This Permit Expires 1 Year From Date Issued_ <br /> Complete In Triplicate) <br /> I :ation is hereby made to the San Joaquin Local Health District for a permit to construct <br /> 'or install the work herein described. This application is made in compliance with San <br /> n �n County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> ;T STREET ADDRESS `� 3 72� SL�<<'�Lgn. CITY/TOWN <br /> ,i s Name Phone9 !�/' 9 <br /> 'Is L - i City /Pd <br /> .-i ctor' s Name e2 Licensg$ jj[5:1 Phone �,K-9lT/ -,72 <br /> :MTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES NO <br /> IF WORK (Check) : NEW WELL L1— DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION [] WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION p�PUMP REPAIRE3 PUMP REPLACEMENT ❑ C�1 <br /> _CE TO NEAREST: SEPTIC TANK/ ,,4—SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> _ PROPERTY LIN RIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> _Industrial Cable Tool Dia. of Well Excavation/��� <br /> Domestic/private Drilled Dia. of We11., Casing—y_ <br /> Domestic/public Driven Gauge of Casing_ /e2 <br /> '-Irrigation Gravel Pack Depth of Grout Seal <br /> _Cathodic Protection Rotary Type of Grout Z <br /> Disposal Other Other Information <br /> --7-Geophysical <br /> =Geophysical Surface Seal Installed by: <br /> ' 'NSTALLATION: Contractor <br /> _ Type of Pump H•P• <br /> ' REPLACEMFNT: ❑State Work Done <br /> ' EPAIR: ❑State Work Done <br /> -RUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> areby certify that I have prepared this application and that the work will be done in accordance <br /> i "an Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local <br /> t 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 /> 1 vs of California." <br /> Lq-- CALL FPR A GROUT INSPECTION PRIOR TO•GROUTING AND A FINAL INSPECTION. p may/ <br /> !Eo TITLE:,-t -� c_ DATE:g04 i A{* <br /> _ <br /> (DRAW PLOT PLEW ON REVERSE SIDE <br /> FOR DEP RTMEN SE ONLY <br /> E I <br /> I�XTION ACCEPTED BY DATE %� <br /> .TNAL COMMENTS: )-7>/ <br /> / <br /> PHASE I GROUT INSPECTION PHASE III FINAL INSPECTION <br /> Ek 'ION BY DATE INSPECTION BY �, DATE 2-J1 <br /> 426 Rav 19-77 1 /7R 9�. <br />