Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> P:�F_FICE USE: 1 1601 E. Hazelton Ave.', Stockton, CA 95205 Permit No. ? - <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Yss td ' zo­0-- <br /> � - <br /> Ir <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 Healt <br /> District. <br /> EXACT STREET ADDRESS a 5'eXl , 6,,o4H. CITY/TOWN <br /> Owner's Name Phone -- 502 <br /> Address S Lad <br /> ,&-& City Low <" <br /> Contractor's Name SoAI �,r c License# � ZPhone _3 377 <br /> IS CERTIFICATE OF 111ORK11AN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES �No, <br /> TYPE Of- WORK-(Check-:=NE f- E-,- DEEPEI��Q�- RECON-DITION [ DESTRUCTION[ <br /> — WELL CHLO~RINATION WELL ABANDONMENT ( OTHER 0 <br /> PUMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK APe-2 SEDER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 1-- CESSP OL/SEEPAGE PIS— OTHER <br /> PROPERTY LIN PRIVATE DOMESTIC WELL_PfJBLI-C D_0 ESTIC WELL <br /> INTENDED USE TYPE OF WELL. CONSTRUCTION SPECIFICATIONS <br /> Industrial , _Cable Tool Dia. of Well Excavation ,e <br /> ,,_Domestic/private Drilled Dia. of Well Casing <br /> Irrigation <br /> Driven Gauge of Casing 4 <br /> Irrigation Gravel Pack', Depth of Grout Seams <br /> —Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> _ Geophysical Surface Seal Inst" ed b : <br /> PUMP INSTALLATION ontractor 6� :E f�vlGGffsv <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: Q State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate-Depth -.-�-- <br /> Describe Materia and Proce ure ._ <br /> I hereby certify that I have. Arepared-.tfi`Ts application and that. the work.will be done in accordancl <br /> with San Joaquin County Ordinances , State Laws , and Ruiesland Regulations of the San Joaquin Ldtal <br /> Health District. Home owner or licensed agent's signature cert_'f.i.es_..the following: <br /> "I certify that in the performance of the work fo-r 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 INSPECTION PRIOR TO GROUTING- AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: /f <br /> DRAW PLT L N ON REVERSE SIDE <br /> PHASE T R DEPARTME.NT USE ONLY <br />�PPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: C� <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY_'q DATE <br /> EH 14 26 Rev. 9/78 ► 9/7$ 2 M _" <br />