Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. ,,.Stockton, CA 95205 Permit No.7 q- C <br /> Telephoner (209), 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued51/-7 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local - Health Dist for a permit, to construc <br /> and/or install the ,work herein described. This application is made in compliance with San <br /> Joaquin County Ordinanc o `� 8 Ru t' o San Joaquin Local Health <br /> District. ��' .� ` e q <br /> EXACT—STREET—ADDRESS �� CITY TO10 <br /> . <br /> Owners Name E -� ���' �1- � Phoneme 3775L6 r <br /> Address cit . , <br /> . <br /> Contractor's Nam ; 9 x <br /> p . Li cense'�373 Phone g <br /> IS CERTIFICATE OF WORKMA144S COMIPENSATION INSURANCE ON FILE WITH-SJLHD? YES4 0 <br /> TYPE- OP, WORK (Check)�;__N EW'WELL b DEEPEN ❑ RECONDITION [ DESTRUCTION N� <br /> WELL CHLORINATION — WELL ABANDONMENT ❑ OTHER(, <br /> ;PUMP INSTALLATION ❑ PUMP REPAIRG2-"' PUMP REPLACEMENT E) <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY Q ' <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT- OTHER - <br /> PROPERTY LINE - PRIVATE D ESTIC WELL PUBLIC DOMESTIC WELL <br /> 4 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 Pro,tection­�,_- Rotary Type of Grout.. <br /> Disposal- - Other ' Other- In`formation " <br /> Geophysical Surface Seal Insta ed <br /> PUMP INSTALLATION: Contractorx ` <br /> Type of Pump H.P. <br /> ,PUMP REPLACEMENT: [I State Work Done <br /> PUMP REPAIR:'. RS-tate Work D AN <br /> "DESTRUCTION-OF'WELL: Well Diameter Yt 4 Approximate Depth <br /> rt Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordanc. <br /> :with San Joaquin County Ordinances , State -Laws , and Rules and Regulations of the San Joaquin -Local� <br /> ilea,lth,. 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 i <br /> not employ any person in such manner as to become subject to Workman's Compensation <br /> laws of California. " j <br /> f WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED , TITLE: DATE: <br /> DR W PLO L N ON REVERSE SIDE <br /> FOR DEP RTME T USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTEDy BY DATE '-1� 7 <br />` ADDITIONAL COMMENTS: _ .- <br /> PHASE-, II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> IiNSPLCTION BY DATE INSPECTION BY DATEef'If <br /> EH 14 26 Rev. 9/78 V V9/78 ZW <br />