Laserfiche WebLink
�) SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> I J Telephone: (209) 466 -6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued _� _�g' <br /> This Permit Expires I 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. F1862 and the Rules 'a Regulations of he .San Joaquin LocaliHealt <br /> District. h <br /> ������ �� .,,� ����� <br /> EXACT STREET ADDRESS r CITY/TOWN <br /> Owner's -Name z Phone- 72 <br /> Address <br /> C i ty S 2-r GA,7,aVJ <br /> Contractor's Name �,t/O? . _- p, e-0, / ,License# e7Z Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO;I INSURAINCE ON FILE -WITH SJLHD? YES NO <br />`TYPE. OF WORK (Check) : NEW WE�LJZL DEEPEN ❑ ' RECONDITION d DESTRUCTION( <br /> WELL CHLORINATION p WELL ABANDONMENT 0 OTHER n <br /> PUMP INSTALLATION E) 1 PUMP. REPAIR❑ PUMP REPLACEMENT C] ' <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 'PIT PRIVY <br /> SEWAGE;DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> PROPERTY LINE PRIVATE DOMESTIC WELL PUBLIC—DOMESTICWELLINTENDED USE k TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial t Cable Tool Dia. of We17 Excavation <br /> Domestic/private it . Drilled Dia. of Well Casing <br /> tly <br /> Domestic/public i Driven Gauge of Casing- <br /> �Irrigation r Gravel Pack Depth of Grout Sea <br /> Cathodic. Protectiont r Rotary Type of Grout <br /> Disposal . F ', Other Other Information <br /> Geophysica:7 Surface Seal Installed by: <br /> F <br /> PUMP INSTALLATION: Contractor <br /> Type ofiPump 4 H.A. <br /> PUMP REPLACEMENT: . []State Work Done <br /> PUMP REPAIR: <br /> (_7State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material an Procedure 4 <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 Dist ' t. Home owner or licensed agent's signature-certifies the following: <br /> "I cer ify hat in the performance of the work for which this permit is issued, I shall <br /> ot <br /> nempl -any perso .,in such manner as to become subject to Workman's Compensation <br /> la s of alifornia <br /> 44 1 <br /> I WIL C L FOR A G O PECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNE -" I TITLE: <br /> _ % ' <br /> Al MDA111 PLO7, PLAN ON REVERSE SIDE <br /> F0 DEPARTMENT USE ONLY <br /> 7HASE I p ,1 <br /> TPPLiCATION ACCEPTED B - DATE/0—/3 <br /> -7 <br />%DDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION <br />'NSPECTION BY PHA E III INAL INSPECTION <br /> DATE INSPECTION 8Y DATE -� <br />'H,1426 Rev.-I2-77 ' <br /> ti �7o nom. <br />