Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br />FOR OFFICE USE: 1601 E. Hazelton Ave., Stockton, CA 95205 Permit No I - <br />Telephone: (2019.1 ) 466-6781 Date Issued <br />APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br />TIHis Permit Ex fres 1 Year From Date Issued <br />-ompl ete, I n Tri p 11 tate <br />a permit to construct <br />Application is hereby made <br />to the San Joaquin Local Health District -for in pcomliance with. San <br />afie/or Install .the work herein described. This application is made n Joaquin Local Healltb-�_ <br />Joaquin County Ord I riance No. 1862 and the -Rules and Regulations of the -Sa <br />District. <br />CITY/TOWNIZ�_Cz <br />EXACT. STREET ADDRESS! <br />Owner's Name4_ C P <br />Address <br />City <br />4 Phone <br />Name • <br />A censeiZKy <br />Contractor's am <br />Ot4 FILE WITH, SJLHD? YE'1� INC <br />T'�, rFRTTIFTCATI OF WOrK!1AN-.S C�TIPENSATION I SURANCE <br />TYPEWOF WORK C] RECONDITION 0!-� DESTRUCTION <br />TYPE,OF WORK ( Check): NEW WELLO DE <br />WELL 'CHLORINATION 0 <br />WELL ABANDONMENT 0 OTHER 0 <br />PUMP INSTALLATION$Ec PUMP REPAIRO PUMP REPLACEMENT 0 <br />I <br />xDISTANCE To NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br />SEWAGE DISPUSAL FIELD C—ES—S-90-L/ SEEPAGE PIT OTHER <br />5F L <br />PROPERTY LINE -. PRIVATE DOMESTIC WELL,..— <br />pusLIC MESTIC <br />INTENDED USE' TYPE OF WELL CONSTRUCTI`ON SPECIFICATIONS <br />Dia. of We I Excavation <br />Industrie— Cable -1001 Dia. of Well Casing- <br />Domestic/private Drilled <br />—Domestic/public —briven Gauge of <br />Casing <br />Irrigation Gravel Pack Depth of Grout Sea] <br />— Cathodic Protection —Rotary Type of Grout <br />Disposal —Other ­OurfacenformaIno <br />t r,lledstaby.: <br />Geophysical <br />PUMP` INSTALLATION: <br />IPUM�P REPLACEMENT: <br />NIMP RePAIR: <br />DESTRUCTION OF WELL: <br />Contractor4 <br />Typelof Purap— <br />State Work Done <br />MState Work Done <br />Wel I I D i ameter Approximate Depth— <br />describe Materia T_an_d_race 7ure__ <br />I hereby certify that I have prepared this application. and that the workwill be done in accordarSan Joaquin Luca <br />"with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the <br />Health District. Home owner or licensed -agent's signature certifies the fellow" <br />III certify that in the performance of the work for which this Permit is isS <br />I shall <br />not employ any Person in such manner as to become subject to workman's Corel <br />anon <br />laws of California." <br />OR TO GROUTING AND A FINAL INSPECTION. <br />I WILL CALL FOR A GROUT INSPECTION PRI <br />TITLE: <br />1-ul" �1` �'2'uv' <br />'I'LL <br />.4 TITLE: DATE: <br />SIGNED cz� IDI <br />MRAW PLUI L ON REVERSE 51Uh) <br />_,1ASE I <br />TP711—CATION ACCEPTED B <br />ADD IT,IONAL COMPIENTS: <br />DwAqIT <br />: 6 -INSPECTION <br />DAT Ej <br />