Laserfiche WebLink
r SAN JUAQUIN LUUAL MtAL[M UIQ I KIL <br /> EOR FFICE USE: /1601 E. Hazelton Ave. , ,Stockton, CA 95205 Permit No. Zi-1-12D <br /> Telephone: (209) 466-6781 <br /> 3 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued A? <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 /> Ioaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> D4strict. <br /> EXACT STREET ADDRESS ,2 E2, A ;/Gt CITY/TOWNscA�� <br /> Owner's Name 141 CPhone (,- <br /> Address -7a 4. e2 uve,6- ALI& City 6SC�94,0-.,) <br /> Contractor' s Name I, 0,S, l .,� .So1 License#���c_ Phone RjP-2207 <br /> _T5 CERTIFICATE OF WORKIIAN'S CO"1PENSATION I"ISURA"ICE ON FILE WITH SJLHD? YES NO <br /> TYPE--OF-WORK (-Check) :- NEW WELD bEEPEN ❑ - RECONDITION [] DESTRUCTION[� � <br /> WELL CHLORINATION 0 WELL ABANDONMENT ❑ OTHER❑ <br /> PUMP INSTALLATION 9 PUMP REPAIR❑ PUMP REPLACEMENT Q t <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 C� <br /> INTENDED USE TYPE OF WELL 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 Sea <br /> Cathodic Protection Rotary , "Type of Grout — <br /> Disposal, Other Other Information <br /> Geophysical Surface Seal Instal ed by: <br /> PUMP INSTALLATION: Contractor ,.., - _ —_— <br /> Type of Pump H.P. --- <br /> PUMP REPLACEMENT: FI State Work Done <br /> PUMP REPAIR: _ ❑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 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 ' 6 bme subject to Workman 's Compensation <br /> laws of California. " <br /> I WILL CALL FOR A GROUTnINSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED j, TITLE: DATE: <br /> (DRAW PLT L N ON REVERSE SIDE) <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY rye- DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE IIJeFINA6 IN PECTION <br /> INSPECTION BY DATE INSPECTION BY DATERa <br /> EH 1426 Rev. 12-77 W178 2M <br />