Laserfiche WebLink
JAN J UAQU I N LUCAL HEAL I M , WU )I K l U l <br /> FFICE USE: 1601 E. Hazelton Ave:., Stockton,- CA 95205 Permit No. �1127 <br /> Telephone: (209) 466-6781 <br /> Date Issued 47 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> �- zZ <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 /> k'oan.:1n County Ordinance N:o. 1862 and the Rules and Regulations of the San Joaquin Local health <br /> District. <br /> �� �� �-� ' <br /> EXACT STREET ADORES J CITY/TOWNs �7r��' <br /> Owner's Name Y. , G Phone <br /> Address 7 City ` <br /> Contractor' s Name P aaw e Liceps Phone2-/ <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION IINSURA1110E ON FILE WITH SJLHD? YES N0 <br /> TYPE OF WORK (Check) : NEW WELLi DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION L] WELL ABANDONMENT ❑ OTHER { ,J <br /> PUMP INSTALLATION)Z PUMP REPAIR 0 PUMP REPLACEMENT ❑ a <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES�0 f-PIT PRIVY [— <br /> SEWAGE DISPO q FIELD - CESS POOL/S EPPAGE PIT ® ETHER C <br /> PROPERTY LINE!-. VRIVATE DOMESTIC WELD PURL C DOMESTIC WELL �— C> <br /> INTENDED USE TYPE OF' WELL CONSTRUCTION SPECIFICATIONS a <br /> Industrial Cable Tool Dia. of Well Excavation12-,fir-LE yDriIled Dia. of Well Casing s2 <br /> Domestic/public Driven - Gauge of Casing C'/es.s_ Z6p/Ds�� <br /> Irrigation Gravel Pack Depth of Grout Seal �p <br /> Cathodic Protection rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLRTION: Contractor ! /2 <br /> Type- of Pump H.P. V-2— <br /> PUMP <br /> yPUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter- 'v 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 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 <br /> laws of California. " <br /> I WILL CALL FORA ROUT I PECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DAT E: <br /> '(DRAW PLOT PLAN ON REV RS SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY102- DATE Z2- 7 <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION. <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> EH 1426 Rev. 12-77 - <br /> 1/78 2M s <br />