Laserfiche WebLink
----- SAN JOAQUIN LOCAL HEALTH DISTRICI <br /> AOR OFFICE USE: 1601 E. Hazelton Ave.., Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6781 <br /> �- APPLICATION FOR WELL C0I45TRUC7ION OR PUMP PERMIT Date Issued - - <br /> This Permit Ex ices 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 /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> D4 strict. <br /> EXACT STREET ADDRESS 5-9162 Al ,� 1j F CITY/TOWN <br /> Owner's Name ALg�a P�-1-6w aSEL Phone &,3 -y_lil?2 <br /> Address_ S A1-1> C i ty.e.,tA�AlTCCA <br /> Contractor' s Name/y NDN-V /NLcZ License# / 6 Q Phone f23- <br /> 7S CERTIFICATE OF WORKMAN'S COr1PENSATIO'lI 1,NSURANCE ON FILE WITH SJLHD? YES V 1140 <br /> TYPE OF WORK (Check) : NEW WELL[, DEEPEN ElRECONDITION ❑ DESTRUCTION[] n <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ 01-HER ❑ <br /> PUMP INSTALLATION 23 PUMP REPAIR❑ PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK /,30 ' SEWER LINES //Q ' PIT PRIVY <br /> SEWAGE DISPOSAL FIELD / -/0 ' CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> YNTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation ZI /#e& <br /> Domestic/private _Drilled Dia. of Well Casing 6 lAlezi eyr22C <br /> X Domestic/public Driven Gauge of Casing /66 &114 1 L <br /> Irrigation _Gravel Pack Depth of Grout Seal <br /> Cathodic Protection �WRotary 'Type of Grout 6 4WO �7- <br /> Disposal Other Other Information.904 <br /> Geophysical Surface Seal Installed �Zz <br /> PUMP INSTALLATION: Contractor � E f— �t, 69 <br /> Type of Pump ,fir �lfews-l417 ;E_ H.P. <br /> PUMP REPLACEMENT: [] 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 accordancf <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 R A GR TOR TO ROUTING AND A FIN& INSP TION. ' <br /> SIGNED TITLE: DATE <br /> : <br /> W PL T PLAN ON REVERSESIDE _ 7 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY v ' DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION S/�/ 9?C-/T <br /> PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE �'°�'�IIONBY DATE -7-/z--;7q <br /> �/ 3; 11 C� <br /> EH 1426 Rev. 12-77 __ -- /78 2M <br />