Laserfiche WebLink
COAX <br /> SAN JOAQUIN LOCALH£ALTH DISTRICT <br /> FICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. l5-33 <br /> Telephone: (209) '466-67'.81 <br /> ' <br />—E-. APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued _. .9 Zg' k <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 hereintdescribed. This application is made in compliance with San <br /> Joaquin County Ordinance No.: 1862 and .the Rules .and .Regul.ations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS I CITY/TOWNS <br /> Owner's Name p / Phone 11 <br /> Address 023^/ , City �T i <br /> Contractor's Name License# _/93 -7iI-Thone _f 1.- - 76 9 � <br /> IS CERTIFICATE OF WORKtiAN'S CO" NSATI0hl3 INSURANCE ON FILE WITH SJLHD? YES NO ! <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION Q DESTRUCTION C] <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 0 <br /> PUMP INSTALLATION ❑ PUMP REPAIR(N PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -, PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL FY . <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private i Drilled Dia. of Well Casing �:' <br /> Domestic/public .1 Driven Gauge of Casing <br /> Irrigation i Gravel Pack Depth of Grout Seal <br /> Cathodic Protection I Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor / -U. AFTS. wa <br /> Type ofi Pump H.P. 12— <br /> PUMP <br /> 2 -PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: L�State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure ' <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 CAL4 FOR A GROUT INSPEC N I GRO TING AND A FINAL INSPECTION. <br /> 00 <br /> SIGNEDfi LE: - DATE:—/ ) <br /> DRAW PL ON REVERSE SIDE <br /> FOR DEP RT ENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYDATE 7 <br /> ADDITIONAL COMMENTS: s <br /> PHASE, II GROUT INSPECTION PHASE I N INSPECTION ' <br /> INSPECTION BY DATE INSPECTION BY ATE _3 <br /> FH 142F' Rpv_ 19-77 1/7&,,.--2M <br />