Laserfiche WebLink
A4�_ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton,"CA 95205 Permit No. 7 2-,Z 6 2 <br /> Telephone: . (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued,l .a 7-,2 2 <br /> •i <br /> k (Complete In -Triplicat' } 4 r <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 i-s made in compliance with San <br /> Joaquin- County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS q 6 S CITY/TOWN Lm <br /> Owner's Name PhoneIf <br /> Address _•C i.tY. ..���, �,�• �'.�..:� <br /> Contractor's Name T� <br /> License# one_ Clol'It 76 ? <br /> IS CERTIFICATE-OF WORKMAN'S CO".P NS TIOt! INSURANCE ON FILE WITH SJLHD? YES No. <br /> TYPE OF WORK (Check) : NEW WELL❑.. DEEPEN ❑ RECONDITION ® DESTRUCTION.0 <br /> WELL CHLORINATION Q WELL ABANDONMENT 0 OTHER Ei -� <br /> ` PUMP INSTALLATION 0 PUMP REPAIR❑ PUMP REPLACEMENT � . <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SPO <br /> { _ SEWAGE DISPOSAL FIELD CESOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE-.DOMESTIC WELL -- PUBLIC DOMESTIC WELL +` <br /> R INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> L ,X Domestic/private Drilled Dia. of Well Casing . <br /> Domestic/public Driven Gauge of Casing <br /> r Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout <br /> isposali Other Other Information <br /> Geophysical - Surface Seal Insta ed b : <br /> PUMP INSTALLATION: Contractor / <br /> ..Type of Pump - H <br /> PUMP REPLACEMENT: State Work Dane <br /> r PUMP REPAIR: -=OState Work Done <br /> BE OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that 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 certifythat in the performance of the work for which this permit is issued, I shall <br /> not employ any person in such manner as to. bec6e subject to Workman's Compensation <br /> laws of California. <br /> ' I WILL -C LL FOR A GROUT:INSPEC I P—PR-14,R TO GROUTING AND A' FINAL INSPECTION. <br /> 7--SI GNE vv= ITLE: <br /> DATE: <br /> D L L ON REVERSE SIDE <br /> SE <br /> OR DEPARTMENT UONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY t DATE —,3/-z- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT. INSPECTION PHASE III FINAL INSPECTION <br /> t. INSPECTION BYDATE INSPECTION BY.,I,11t�'-1. DATE, —2l^ <br /> SEH 14 '26 Rev. 9/78 - _ <br /> �i 9/7R 2M <br />