Laserfiche WebLink
SAN JOAQUIR LOCAL HEALTH DISTRICT <br /> �FFICE USE: 1601 E. Hazelton .Ave. , Stockton, CA 95205 Permit No Z7 <br /> Telephone: (209) 466-6781 ` <br /> Date Issued ,3— V. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> - <br /> This 'Permit Expires 1 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. 1862 and. the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT 'STREET ADDRESS L 00"/s -que- CITY/TOWN S IOCh(1 A-) j <br /> Owner's Name Md- A I LA 8 fi!i1GHe t?% - — Phone' 12.30 <br /> .Address 7 . S 9 `i City _-- <br /> Contractor's Name C/,Ofj/f r 4a/, License#JL D, Phone 2-5-,I�g� <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATI0,1 INSURANCE ON FILE WITH SJLHD?' YES Nq <br /> TYPE OF WORK (Check) : NEW WELL)Q DEEPEN CI RECONDITION [] DESTRUCTION <br /> WELL CHLORINATION 0 WELL ABANDONMENT p OTHER 0 -_---- <br /> PUMP INSTALLATION 0 PUMP REPAIR 0 PUMP REPLACEMENT [� N <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY 0", <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER 0 <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL t <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> _ xIndustrial ( F Cable Tool Dia. .of Well Excavation <br /> Domestic/private Drilled - Dla. of Well Casing <br /> Domestic/public �. Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal . Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: [] State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL:, Well Diameter Approximate Depth <br /> Describe Material and Proce ure <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 FORINSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. ! <br /> SIGNED TITLE: DATE: <br /> (DRAW PLOT PLAW ON REVERSE SIDE . <br /> FOR DEPARTMENT USE- ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY :9� <br /> ,DATE 3 D <br /> ADDITIONAL COMMENTS: U / <br /> PHASE II GROUT INSPECTION PHASE III FMAL INSPECTION <br /> INSPECTION BY t DATE 17 INSPECTION BYDATE v rL <br />—EH 126 Rev. 12-77 1/78 2M <br />