Laserfiche WebLink
P2�6FICE <br /> SAN JOAQUIN- LOCA1 .HEALTH DISTRICT <br /> USE: 1601 E. Hazelton. AveStockton, CA 95205 Permit Na.Telephone: . (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued '- <br /> This PermitEx ares 1 Year From: Date Issued <br /> Complete In Triplicate) . t <br /> I <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct ' <br /> a6d/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 c.fel - ,-r5F,� CITY/TOWN <br /> Owner's Name - T 11 Phone `' / / <br /> Address.- <br /> [ -c.cr r City <br /> Contractor' s Name aj, � License# 04� Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO11 . I-11SURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) NEW WELL M' DEE'PEN-0 RECONDITION Q DESTRUCTION <br /> WELL CHLORINATION 0 WELL ABANDONMENT Q OTHER 0 � <br /> PUMP INSTALLATION-[] PUMP REPAIR❑ . PUMP REPLACEMENT, <br /> DISTANCE TO NEAREST: SEPTI.C, TANK SEWER LINES PIT PRIVY <br /> SEWAGE 'DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -, PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> Iei <br /> INTENDED USE -TYPE OF_. W.CLL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. 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: Contractor47-1 << l <br /> I Type of Pump � �- H.P. d <br /> PUMP REPLACEMENT: Q State Work Done <br /> PUMP REPAIR: Os tate Work Done <br /> DESTRUCTION OF WELL: Well: Diameter Approximate Depth <br /> Describe Matbrial and Procedure <br /> I.-hereby-certify that-I have prepared this application and that the--work-wi-1-1- -be- done in accordance <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Locale <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 Wgrkman' s Compensation <br /> laws of California." - <br /> I WILD CALL FOR A UOUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: 5 <br /> ����DR�WPLQ�TPL N ON REVERSE SIDE <br /> PHASE I NT <br /> FOR DEPARTMEUSE ONLY <br /> APPLICATION ACCEPTED BY s DATE -3f-7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT IN ECTION . PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br />-P- 1426 . Rpv 19-77 --- —� A 7Q ')M <br />