Laserfiche WebLink
F SAN JOAQUIN_ LOCAL HEALTH DISTRICT <br /> Stockton, CA 95205 Permit No. _/.s <br /> 'CE USE: � 1601 E. Hazelton Ave. , � ,-. - <br /> ' ' Telephone: (209} 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <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 app,11 cation is made in compliance with San- <br /> I- <br /> an• <br /> I-oaquin County Ordinande No. 1862 and the Rules -and Regulations of the San Joaquin Local, Health <br /> District. <br /> EXACT STREET ADDRESS O - A CITY/TOWN i ca <br /> �J <br /> Owner's Name I n Phone 9 3 3 <br /> Address Ci tya,' — <br /> F Contractor's Name �lh;r- 11Ar�wa. e t "`License#33 7 Phone -3a3 <br /> *S CERTIFICATE OF WORKMAN.'S COIMPENSATIO'N I'NSURA?SCE ON FILE WITH SJLHD? YES NO Y <br /> TYPE OFWORK (Check) : NEW WELL Q ^ 4 DEEPEN Q RECONDITION'Q `DESTRUCTION[ <br /> WELL CHLORINATION Q WELL ABANDONMENT 0 OTHER ED c <br /> .PUMP INSTALLATION PUMP REPAIR 0 PUMP REPLACEMENT []I I' <br /> DISTANCE TO- NEAREST:. �.�:SEPTIC TANK SEWER LINES PIT PRIVY <br /> HISEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> I1`PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE'OF WELL CONSTRUCTION SPECIF CAS TIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> �- "Domesti.c/private ,I,-7Dri11ed Dia. of Well Casing_ .` <br /> Domestic/public Driven Gauge of Casing _ <br /> Irrigation (� �:_Gravel Pack Depth of Grout Sea 4"rn <br /> Cathodic Protection _-fttary . Type of Grout c <br /> Disposal j Other Other Information <br /> Geophysical I: Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. S <br /> PUMP REPLACEMENT: C] State Work Done <br /> F PUMP REPAIR: Q State Work Done <br /> rDESTRUCTION OF�WELL:- Wel l - Diameter - - • -Approx,i-ma-te-Depth -' <br /> Describe Material and Procedure <br /> I hereby certify that ]i have prepared this application and that the work will be done in accordan <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Loca <br /> Health District. Homeowner or licensed agent' s signature certifies the following: <br /> "I certify that in 'lhe performance of the work for which this peimit is issued, I shall <br /> not employ any person in such manner as to become subject to Workman' s Compensation <br /> laws of California'." 4i' <br /> 1 WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED it TITLE: •Wrv%',_e M e r DATE:�7$ <br /> it <br /> (DRAW PLT PLAN ON REVERSE SIDE <br /> F D ARTMENT USE ONLY <br /> PHASE I 11 DATE <br /> APPLICATION ACCEPTED B <br /> ADDITIONAL COMMENTS: IN <br /> PHASE II -.GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY AIA 1 DATE INSPECTION BY E S = DATE' %/-1 <br /> YIT <br /> EH 1426 Rev. 12-77 �� � c� -- 1/78 2M <br />