Laserfiche WebLink
�FF <br /> SAN JOAOUIN LOCAL H1 ALCH U!SIkILI <br /> E USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. J! JP7 <br /> Telephone: ,. (209) 466-6781 <br /> APPLICATION FOR TELL CONSTRUCTION OR PUMP PERMIT Date Issued _?-17 <br /> This Permit Expire s <br /> x ires 1 Year From Date Issued <br /> Complete In Triplicate <br /> Application is hereby made to the San Joaquin Isocal Health District for a permit to construct <br /> and/or install the work herein described. This 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. <br /> EXACT STREET ADDRESS ern cc,aae, A-l/m CITY/TOWN <br /> Owner' s Name Phone <br /> Address3 rm w m-a City C <br /> Contractor's Name ee.w License &,3 73, hone (y �, <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO"1 INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL CI DEEPEN 0 RECONDIITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION Q WELL ABANDONMENT p OTHER ❑ <br /> PUMP INSTALLATION 0 PUMP REPAIRP9 PUMP REPLACEMENT Ea <br /> DISTANCE TO NEAREST: "' SEPTIC TANK SEWER LINES PIT PRIVY .1 <br /> SEWAGE DISPOSAL FIELD , CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -, PRIVATE DOMESTIC 'WE°LL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable'Tool Dia. -of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casind <br /> Domestic/public Driven Gauge of Casing <br /> _Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary <br /> —Disposal Type of Grout <br /> Other Other Information �I <br /> Geophysical Surface Seal Installed by-: <br /> PUMP INSTALLATION: Contractor 4y/_ i , <br /> Type of Pump ✓ H, '-✓ <br /> PUMP REPLACEMENT: Q State Work Done <br /> PUMP REPAIR: (State Work Done 40 day ltlr ' <br /> DESTRUCTION OF WELL: Well DiameterApproximate Depth <br /> Describe Material and Procedure <br /> f � <br /> I hereby certify, that I have prepared this application and that the -work will be` done •in- accordancd <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 folio-wing: <br /> "I certify that in the performance of the work for which this permit is issued, I shall G <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 PRIG TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED <br /> TLE: DATE: <br /> W LOT <br /> PLW ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE /� g <br /> ADDITIONAL COMMENTS: r <br /> PHASE II GROUT .INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY--%,V,,, DATE INSPECTION BY <br /> DATE <br /> LH 1426"' Rev. 12-77 � .1 17R i <br />