Laserfiche WebLink
SAN JOAQUIN -LOCAL HEALTH DISTRICT <br /> AOR 4FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: {209} 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued /—/,o _2 <br /> This Permit Ex ' i res' I =Year .From Date Issued - <br /> '� l:Zt . ry 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 Health � <br /> District. <br /> .EXAICT STREET ADDRESS 960I 1td <br /> CITY/TOWN B <br /> Owner's Name AA1 6ZILe - Phone(A. -- 94 9 <br /> Address S3.S '9-V&- Z/p q4-?¢7 Ci V_&&1114-7-429 <br /> Contractor' s Name i cense#532t9 2-Ahone7S-9--3 37 7 <br /> _ ± <br /> IS CERTIFICATE OF WORKMAN'S C0!1PENSATION INSURANCE ON FILE WITH. SJLHD? YES- <br /> TYPE OF"WORK (Check) : -NEW-WELLO '' - DEEPEN-O_w� ---;- .� <br /> - `RECONDITTON-® "�DESfiRUCTION� `.-� <br /> i F WELL CHLORINATION Q WELL ABANDONMENT 0 OTHER 0 � <br /> 4� PUMP. INSTALLATION [ PUMP/ REPAIR[] PU.MP REPLACEMENT ❑ - <br /> DISTANCE TO NEARE`ST_:. SEPTIC TANK /M/ SEWER ;LINES PIT PRIVY a <br /> -�SEWAGE� DISPOSAL FIELD d J,CESSPOOL/SEEPAGE PITOTHER `' N <br /> PROPERTY LINE -, PRIVATE DOMESTIC WELL PUBLTC DOMESTIC WELL <br /> INTENDED USE <TYPE OF WELL <br /> industrial ` " f CONSTRUCTION.SPECIFICATION5 <br /> ^, Cable Tool Dia. of Well Excavation / -!� ° <br /> Dom6gti c/private g- v, - - —T <br /> '1�! Drilled � I Dia. of Well Casi•n �:,A <br /> - c �-- a --TT _ <br /> Domest��"/�b1=i� _-�-- Dr�-ven .-�� "� ��Gauge of'�C'as-i ng j�---- - ^h <br /> _ Iri^igation . ` Gravel Pack" Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: /r.fiG�_F-- <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: ❑State Work Done ' ] <br />.D.ESTRUCT.ION_OF-WELL:. . Weil Diamete.r,�.:_- <br /> Describe MateriaT and Proce ure —Approxi.mate-De.pt.h . <br /> I hereby certify that I have prepared this application and that the work will be done in lccordance� <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 fithe 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 WDrkman's Compensation f <br /> laws of California. " F <br /> I WILL CALLA FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: 3 <br /> (DRAW PLT PLAN ON REVERSE SIDE) <br /> € <br /> PHASE I FOR DEPART NT USE ONLY <br /> � <br /> APPLICATION ACCEPTS B,Y -2z..z DATE d r- 9 wf <br /> ADDITIONAL COMMENTS: . J V IF <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> S <br /> EH 1426 Rev. 12=77 ,. ,'70 l{ <br />