Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE`USE:" 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Tel ep.ho.ne:_�(209) 4666781 pate Issued <br /> I. APPLICATION FOR4WELL4CONST=Rt]CTION OR PUMP PERMIT <br /> ir.es . I Year From Date Issued <br /> Thy.'s Permit Ex <br /> Co P1 In Triplicate <br /> Application is hereby made to!Ithe San Joaquin Local HealthDiis made in strictfor a permit to construct <br /> and/or `instaTT" the work herein described. 'This <br /> s. andlication ons of the San pJoaquin liance wLocalith aHealth , <br /> Joaquin County Ordinance �No-. 1862 and the ► <br /> District. <br /> R � �1 l - <br /> EXACT, STREET ADDRESS ��1 <br /> Phone - <br /> Owner`s Name B o + <br /> City .. <br /> rA­ <br /> Address �. <br /> 1 Lt- <br /> IS <br /> C icf Li cense#3 0 Z.Phone <br /> Contractor's Name ' I Bow - -- - <br /> "! IPLSURANCE ON FILE WITH SJLHD? YES Ia0 <br /> IS CERTIFICATE. OF WORKMAN'S CO"iPENSRTIO1, <br /> TYPE OF WORK (Check) :___NEW_WELLCL- _ DEEPEN_L1r _ RECON.DITION.--____pESTRUCTION <br /> T WELL CHLORINATION 0 - WELL ABANDONMENT �-OTHER( -- �� <br /> PUMP INSTALLATION 0 PUMP REPAIR❑ PUMP REPLACEMENT ] <br /> DISTANCE TO NEAREST: SEPTIC TANK 60r SEWER LINES 5 7) r- PIT PRIVY <br /> -, SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE4P PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL _ <br /> . i TYPE OF WELL CONSTRUCTION ,SPECIFICATIONS, I <br /> INTENDED USE <br /> Industrial Cable Tool Dia. of Well Excavation /! " ff <br /> Domestic/private Drilled q3'- Di a.:"'`of,�We1-1 �CaS i ng <br /> - Gauge of-Casyng /� T <br /> —7D_b e` s 61p6bl i c _ D�^�ven <br /> - Ii^ri gati on , Gravel Pack Depth of 'Geout Seal <br /> Cathadi c° Pr�te.cti on Rotary Type of Grout li <br /> Disposal ; Other Other Information <br /> I Geophysical Surfade •Seal `Instal ed b <br /> PUMP INSTALLATION: Contractor <br /> > Type of Pump : <br /> PUMP REPLACEMENT': '71 state Work Done a�. •. , ' �- <br /> i � A <br /> ❑State Work Done <br /> PUMP REPAIR: � � _ at - <br /> k ! Approxime-Depth <br /> DESTRUCTION OFEWELL: Well Diameter ` <br /> Describe Materia . and Proce ure <br /> I hereby certifyrthat I have prepared this application and that the woonswoflthe„`Sanein JoaquinoLocal <br /> 1. <br /> ' State taws , and Rules and Regulations <br /> I with San Joaquin, Ordinances , <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 Compesation <br /> laws of California.” 1 <br /> I WILL CALL FOR A GR T INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: <br /> DR W PLT E ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE. I DATE - <br /> I APPLICATION ACCEPTED BY � , <br /> ADDITIONAL COMMENTS : PHASE III FINAL INSPECTION <br /> PHASE II GROUT. INSPECTION DATE <br /> INSPECTION BY IDATE INSPECTION BY <br /> 1/78 2M <br /> � anc f7.... 19_77 <br />