Laserfiche WebLink
SRN JUAQU1N LUf:NL HtRL I N U15 I Kll: I <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. e_ 6 �- <br /> Telephone: . .(209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued /)-- 9 meg'; <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 application is made in compliance with San ' , <br />,oaauin County Ordinance No. 1862 and the ,Rules and Regulations of the San Joaquin Local Health <br /> Distr?ct. <br /> EXACT STREET .ADDRESS 9CITY/TOWN <br /> Owner' s Name Com' Phone <br /> Address I .Ci ty. i <br /> Contractor' s Name - , kicense ,r Phone G' <br /> r —L <br /> &b <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION! INSURAN ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL My' DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ -� <br /> WELL CHLORINATION ❑ WELL ABANDONMENT Q OTHER❑ -� <br /> PUMP INSTALLATION MP REPAIR❑ PUMP REPLACEMENT [ �' <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY C <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cbl e Tool Dia, of Wel l Excavation <br /> mestic/private ,., Drilled Dia. of Well Casing A. <br /> Domestic/public Driven Gauge of Casing , <br /> Irrigation G�r vel Pack Depth of Grout Seal g <br /> Cathodic Protection Rotary Type of Grout ;r-- <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: ' <br /> PUMP INSTALLATION: i, Contractor' <br /> .. S' r <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: ❑Sta eWork Done <br /> DESTRUCTION OF WELL.: WellFDiam_ eter Approximate Depth j <br /> Describe Material' And Proce ure j <br /> k � <br /> I hereby certify that I have prepa'red this application and that the work will be done in accordance <br /> with San Joaquin County Ordinances,:4State 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, manine:r as ,to become subject to Workman's Compensation <br /> laws .of California. " "'. 11 J+ <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNEDTITLE: - DATE: <br /> (DRAW PLOT PL N ON REVERSE SIDE <br /> PHASE I <br /> FOR DEPARTME T USE ONLY :fee:fee5; P r►� S 1243 <br /> ;� -!2!02.3 <br /> APPLICATION ACCEPTED BY DATE Ej�29�75 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY_1(,}.,\ �� DATE �,tiT.._� INSPECTION BY_�C, --\ DATE ti� <br />