Laserfiche WebLink
SAN JOAQUTN� LgCAt HEALTH DISTRICT � <br /> OFFICE USE. 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.�_. <br /> - Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued - - <br /> This Permit Expires 1 Year From -Date 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 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 /> D i s t r i c t. • 12,6 r AlC �7�'—�c ��-4-v-F . <br /> EXACT STREET ADDRESS G --Tn,,j0� acv_ � �,�o_� CITY/TOWN <br /> Owner.'s-.Name �� � �.����r r��-ter �- S� c� t2.�-. Phone 4-('o Ca -z t s� <br /> Address-:,, City 0,3 - <br /> Contractor's Name- C,, License#2 SS' Phone 46,C,-z1 b S7- <br /> IS CERTIFICATE OF WORKMAN'S 6OMPENSATIOIN IINSURANCE ON FILE WITH SJLHD? YES K 4140 ry <br /> TYPE OF WORK (Check) : NEW WELLED .'DEEPEN CI RECONDITION C3 DESTRUCTION <br /> f <br /> WELL CHLORINATION E3 WELL ABANDONMENTS OTHER 0 <br /> PUMP INSTALLATION 0 PUMP REPAIR p PUMP REPLACEMENT [I C <br /> DISTANCE TO NEAREST: SEPTIC TANK/�d' SEWER LINiSJs'a 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/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotfry° — T Type of-Groin <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump ` �.H.P. <br /> PUMP--REPLACEMENT: ❑ State Work Done ^11 � . - . <br /> PUMP- REPAIR: <br /> QState Work Done _ .��a <br /> DESTRUCTION OF WELL: Well Diameter /ar 12 `� Approximate Depth -.�ZoC> <br /> Describe Mate'rial and Proce ure -F, ti-r- _ <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: <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 mariner as to become subject to Workman 's Compensation <br /> laws of California." <br /> I WILL CALL FOR A GROUT - -NSPECTI IOR TQ,—,GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: 2� 1 <br /> DRAW PLAN ON REVERSE SIDE) -- <br /> f-FOR,DEPARTMENT/USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY Ff D TE V <br /> /7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE..-III/FIL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> Cu 1n"Jc n_.. '1n '77 7 /7Q 7M <br />