Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br />__moo .OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued—/"-/- 7 <br /> This Permit Expires 1 Year From Date Issued <br /> Complete In Triplicate) ��S—AZO -t7 <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. rThis application is made in compliance with San <br />,oaQuin County.. Ordinance No. 1862 and the Rules and Regulations of the San. Joaquin Local Health <br /> District. 44-tf�. /AA,3& C— Aacrmj go <br /> EXACT STREET ADDRES% _&,,_7rx. ;U c „Al Je j /'i.�iyc�s✓ CITY/TOWN <br /> Owner's Name A c_v b - 0-A T; znr= Phoneme- -/S__ - 1•2d 2,:7� <br /> Address o &e &,g c Ci ty 5,0 'y <br /> Contractor' s Name A,M i c.e n s e f,2g1f2t7 <br /> Phone, � <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO'N ItISURANCE t FILE WITH SJLHD? YES v NO <br /> TYPE OF WORK (Check) : NEW WELW„_ .DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION 0 WELL ABANDONMENT ❑ OTHER❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK IVI SEWER LINES (dXrt:-PIT PRIVY m <br /> SEWAGE DISPOSAL FIELD p CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE�DPRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFI &TIONS d <br /> Industrial Cable Tool Dia. of Well Excavation <br /> L, Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing / <br /> Irrigation Gravel Pack Depth of Grout Seal �T <br /> Cathodic Protection t--Rotary Type of Grout <br /> Disposal Other Other Information T <br /> Geophysical Surface Seal Installed by: � <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: [JState 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 FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE• .H DATE: // ' <br /> DRAW PLOT— PL N ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE-III A INS . zON <br /> INSPECTION BY DATE INSPECTION BY DATE <br />-H 1426 Rev. 12-77 1_J78 2M <br />