Laserfiche WebLink
r ✓ SAN JOAQUIN .I.00AL�HE�ALTH DIS RlCT <br /> ffFOR FFICE USE: 1601 E. Hazelton Ave. ;"Stockton, CA 95205 Permit No.2L_04 <br /> Telephone: (209) 466-6781 <br /> # APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued J7_ <br /> 4 <br /> This :.Permit •Ex i res 1 Year From Date Issued � 6/r� $ <br /> Complete In Triplicate � °- <br />: Application is hereby made to the San Joaquin Local. Health District for a permit to constriuct) : <br /> and/or install the- work. here'i.n described. This application is made in compliance with- San <br /> Joaquin County Ordinance No. 1862. and the Rules and Regulations. of th San Joaquin Local Health <br /> District. �p►r�► �k&vQ i � c <br /> { <br /> EXACT STREET ADDRESS 7� CITY/TOWN 4-c['1giCoscl <br /> Owner's Name L P14p T 14 G v 771 Phone <br /> Address4 k7-)f City_of&-A71 .� <br /> Contractor' s Name. -ro. r' License# .2 Phone$' -cga?o 7 <br /> _'S CERTTFICATC�OF`I�ORKMAVS COMPENSATION IISURA^ICE ON FILE WITH SJLHD? YES � NO <br /> TYPE OF IdORK NEW WELL C�� DEEPEN ❑ RECONDITION ® ' DESTRUCTIO [� Tzr+i/�7��7avrot <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER (� �.,�,�-.4: 0ww6c- <br /> PUMP INSTALLATION E_ PMP REP R PU P RE LACEME T [3 <br /> DISTANCE TO NEAREST. SEPTIe. <br /> C TANK SEWER LINES .1RILT PRIVY <br /> SEWAGi DISPOSAL FIELD . CESSPOOL/SEEPAGE PIT- OTHER O <br /> PROPERTY LINE - PRIVATE DOMESTICvWELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable .Tool Dia. of Weil Excavation <br />�4 <br /> Domestic/private 4 Drilled N a of Well Casing <br /> Domestic/public Driven Gauge of-Casing <br /> Irrigation-- -Gr-a-vel .-Pack. -..-._... .Depth-o-f Grout Seal - -- -. <br /> Cathodic Protection ' Rotary , Type of Grout 5 ; <br /> a <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor „ � ! <br /> Type of Pump f. �, = ;H.R <br /> PUMP REPLACEMENT: Q State Work Don �3?i- , • <br /> PUMP REPAIR: ❑State Work Done r <br />�DESTRUCTION OF WELL: Well •Diameter Approximate=Depthzi <br /> • <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 per:fo•r-mance oflthe work for which this permit is issued, I shall <br /> not employ any person in such manne.rA.as to become subject to Workman's Compensation <br /> laws of California." <br /> I WILL CALL F A GROUT I PEC ON PRIOR TO GROUTING AND A FINA INSPECTION. <br /> SIGNED TITLE: DATE: <br /> DRAW PLT L N ON REVERSE SIDE ' <br /> F R DEPARTM NT USE ONLY <br /> PHASE I <br /> APPLICATION ,ACCEPTED BY DATE / <br /> /79- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT S C ION PHASE/ III E NAL INSPECTION <br />` INSPECTION:BY P:-, DATE INSPECTION BY DATE <br />;:EN 14ZE- -Rev_ 12-77 1 I7A' 9M 1 <br />