Laserfiche WebLink
SAN JUAQU 1N`1UUAL' HLAL l H U 151 RI L l <br /> OFFICEFOR USE: 1601 E. Ha,zel1on Ave: ; 4Stockton, CA 95205 Permit No. �G - �b�i __ <br /> telephone: (209) 466-6781 <br /> APPLICATION. FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued -z -7I <br /> This Permit Ex fres I Year From Date Issued <br /> Complete In Triplicate 2-53-�-155-0c D(� <br /> i <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 compli.ance. with San - <br /> Joaquin County Ordinance No. 1862 and rthe „Rules and Regulations of the San Joaquin Local Health <br /> District. kc— t <br /> EXACT STREET ADDRESS je /l/ b (LOF-5 ITY/TOWN nqc <br /> Owner' s Name Fz R 14 61 C O <br /> Phoned <br /> Address City 1�C <br /> Contractor' s Name! ht 1 N b5 License / Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO"! INSURANCE ON FILE WITH SJLHD? YES �- NO <br /> TYPE OF WORK (Check) : NEW YELLIM DEEPEN 0 RECONDITION ❑ DESTRUCTION❑ � <br /> WELL CHLORINATION 0 WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT ❑ v.+ <br /> DISTANCE TO NEAREST: SEPTIC. TANK SEWER LINES PIT -PRIVY <br /> PRIVATE <br /> CESSPOOL/SEEP_ E PIT OTHER w <br /> SEWAGE�`:DISPOSAL FIELD �-- � <br /> PROPERTY LINE -. DOMESTIC WELL PUBLIC DOMESTIC WELL�.�-8 <br /> INTENDED USE ;;�` TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing is <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation =Gravel Pack . Depth of Grout Seal <br /> Cathodic Protection x Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed b <br /> PUMP INSTALLATION: Contractor H. ;I <br /> Type of Pump <br /> PUMP REPLACEMENT: F] State Work Done <br /> ' I <br />' PUMP REPAIR: Q State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Dept} <br /> F Describe Material and Procedure <br /> } <br /> I hereby certify that I have prepared -this application and that the work will be done in accordant( <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 FOR A 'GROUT_INSP�ECJ4ON PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE:/ <br /> (DRAW PLOT TLTN ON REVERSE SIDE <br /> �{ FOR DEPART E ONLY <br /> IPHAS E��I ' � :,....��,.. . <br /> APPLICATION ACCEPTED BY DATE &_ <br /> [. ADDITIONAL COMMENTS: <br /> - PHASE II GROUT iNSPECTIO PHASE III FINAL INSPECTIO-q�Nl <br /> INSPECTION BY ATE _ INSPECTION BY � DATE L' a-� <br /> 2M <br />