Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. L/' ? <br /> Telephone: (209) 466-6781 E <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued-WELL <br /> ssued y- 7 } <br /> 9 <br /> Thi's Permit Ex iIres 1 Year .From Date 'Issued . y 9-7--o 74 6 <br /> Complete I n Triplicate) � y �i <br /> Application Iis hereby made to the San Joaquin TLocal .Health District for a permi� to construct <br /> and/or install the work herein. described. :T.hi,s application is made in compliance with .San <br /> Joaquin County Ordinance No. 18. 62 and: the Rules and Reg,ulations of the San Joaquin Local Health <br /> District. � ��' �"''� ��-17�'P <br /> EXACT STREET ADDRESS . <br /> � - CITY/ <br /> TOWN � <br />�`1Qame .� Phon V _ �3S"• <br /> Address ti- J LAJ.. 77" <br /> Contractor' s Nam ,' License Phon �� .3o a <br /> ., , I <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIOij I11SURANCE ON FILE WITH SJLHD? YES ✓ ,,10 <br />_ <br /> TYPE OF WORK (Check) : NEW WELL M DEEPEN El ; RECONDITION ® DESTRUCTION❑ <br /> WELL CHLORINATION Q WELL ABANDONMENT ICI OTHER 0 -- <br /> PUMP INSTALLATIpN - _. PUMP ..REPAY_ PUMU.ERLAC.ME.NLEJ <br /> DISTANCE TO NEAREST: SEPTIC TANK`;S-E'WER---I;I-NE-S PIT PRIVY — # <br /> SEWAGE DISPOSAL'FIELD_ -Yn'°CESSPOOL/ E PAGE PIT, OTHER <br /> . : -' <br /> PROPERTY L:IN _ARIUATE�DOMI=STIC WELL PU.BL:IC_,DOMESTIC WELL' <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICA IONS - 1 <br /> Industrial F Cable Tool Dia. of Wel1 �Ex 'avation <br /> Domestic/private j7 Drilled. Dia. of Wel'1' Casing <br /> Domestic/public Driven Gauge of,�C, sing -V <br /> Irrigation Gravel Pack Depth of..Grout Sea 'Ah. <br /> Cathodic Protection Rotary Type of Grout } <br /> Disposal --Othcr_. Other Information <br /> Geophysical ,..v) Surface Seal Installed b . <br /> r , <br /> PUMP INSTALLATION: Contractor 11e �• <br /> Type ,of Pump ! P: ` <br /> PUMP REPLACEMENT: State-Work''Done` ' <br /> PUMP REPAIR: Q 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 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 I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: // -73 <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FO SPAR M£NT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY p DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE ISI . INAL NSPECTION <br /> INSPECTION BY DATE i.-13 7 INSPECTION BY DATES 2��/ <br /> 1/76 2M <br />