Laserfiche WebLink
bra /a �� ., <br /> `'� SAN JOAQUIN,.LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.7 7_ <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR -WELL CONSTRUCTION OR PUMP PERMIT Date Issued ff- <br /> +moi p l c a e) <br /> (Eomp1ete �In Tri i t <br /> 1 . Application is hereby made to the .San Joaquin Loca._Health District for a permit to construct. <br /> -and/or .i.nstall the work hereinlA escribed. Thfs application: is made in compliance with San ` <br /> Joaquin County-Ordinance No:; 1862 and the 1tul.es apd' Regulations of the San Joaquin -Local Health <br /> District. , <br /> f EXACT STREET ADDRESS -4a CITY/ <br /> Owner's Name �" _ <br /> Phone <br /> Address.6. � Cit T <br /> y_._ <br />! Contractor's Name )A& License#zfd 2,;.tfl ohe �7- <br /> IS CERTIFICATE OF WORKMAN'S <br /> C 04£N?AT I0N INSURANCE ONJILE WITH SJLHD? YES 0 <br /> f <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN 0 � RECON56'1ON [3 DESTRUCTION,[ <br /> WELL CHLORINATION Q . WELL ABAIVOONMENT 0 OTHER(,. <br /> PUMP INSTALLATION M , PUMP REPAIRED PUMP REPLACEMENT " a <br /> ' h <br /> DISTANCETO NEAREST: SEPTIC TANK SEWER LINES ..,}, PIT PRIVY N` <br /> SEWAGE DISPOSALFIELD GESSP L/SEEPAGE PIT OTHER <br /> G ; <br /> -PROPERTY LINE - PRIVATE DOMESTI-C. WELL PUBLIC D MESTIC WELL �!il <br /> I�TENDED USE TYPE OF -WELL. CONSTRUCTION SPECIFICATIONS' <br /> Industrial . �.. <br /> Cabl a Tool Di a'. 'of Well Excavation <br /> Domestic/private Drilled Ria. of Well Casing <br /> Domestic/public Driven : -,- Gauge of Casing <br /> X Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout <br /> ,� <br /> Disposal - 4- Other -. Other Information 1 <br /> �Geophysical Surface Seal Inst- ed <br /> PUMP INSTALLATION:. Contractor <br /> i. ._ . . Type of Pump H.P. <br /> PUMP 'R�• State Work Done --- <br /> h <br /> PUMP REPAIR: Q State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate-Depth - <br /> Describe Material and Proce2ure� , <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 manner as to become subject to Workman's Compensation `�'U <br /> laws of'California." <br /> I WILL CALL •FOR A GROUT' INSPE ON TO GROUTING' AND A'-FINAL INSPECTION. / <br /> SIGNED ITLE:' DINE: IS <br /> PL T L N REVERSE SIDE <br /> OEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY s 17, <br /> } <br /> ADDITIONAL COMMENTS: DATE 1--2 i <br /> PHASE II GROUT INSPECTION PHA E II FINAL INSPECTION <br /> INSPECTION BY DATE � INSPECTION BY DATE <br /> Efl. l4 26 Rev. 9/78 <br />