Laserfiche WebLink
in I Vvn4V 4 1 4va.nL i 1L111_111 VL.J 1 1.46v I <br /> F ICE USE: 1601 E. Hazelton Ave, , Stockton, CA 95205 Permit No-, rL,a-2:5 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 8� f <br /> This Permit Ex fres 1 Year From Rate Issued y <br /> (Complete In Triplicate) ' <br /> pplication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> d/ur install the work herein described. This application is made in compliance with San <br /> aquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> Strict. <br /> IACT STREET ADDRESS �'Z. �� I C` �� CITY/TOWN <br /> ne r's Name 1 C"s[R Y L Cr C- } Phone a G <br /> dress 20 C,0 5 .�T C-44 RTfk Lt)R City ST C t -reju <br /> retractor' s Name�0 L A _E L LM ?MfA;7 eO Li cense# (- a- Phone 41& 2 <br />[S CERTIFICATE OF WORKMAN'S COMPENSATIO"t INSURAINCE ON FILE WITH SJLHD? YES <br /> PE OF WORK (Check) . NEW WELL DEEPEN [] RECONDITION d DESTRUCTION❑ <br /> WELL CHLORINATION Q WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION E3 PUMP REPAIR❑ PUMP REPLACEMENT 0 <br /> STANCE TO NEAREST: SEPTIC TANK 5V SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELDS CESSPOOL/SEEPAGE Tff— OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUSLFC DO'iESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION! SPECIFICATIONS <br /> ndustr a Cable Tool Dia . of We Excavation / <br /> Womestic/private Drilled Dia. of Well Casing <br /> I ' <br /> Domestic/public Driven Gauge of Casing X9/d <br /> Irrigation vel Pack Depth of Grout Sea ' <br /> Cathodic Protection Rotary Type of Grout e1eg1FaJT <br /> on <br /> Disposal Other Other Informat <br /> Geophysical Surface Seal Insta ed <br /> MP INSTALLATION: Contractor L AQK WELL " E UI PHE vT !Co- div <br /> Type of Pump—Lt 80EJIc <br /> MP REPLACEMENT: []State Work Done <br /> MP REPAIR: QState Work Done <br /> STRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> ihereby certify that I have prepared this application and that the work will be done in accords* <br /> th San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Loc, <br /> alth 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 to such manner as to become subject to Workman ' s Compensation <br /> laws of California " <br /> WILL LA6 FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> t E0 dam. TITLE: OwAiriz, DAT E:,Z 2 /1tlC 7f <br /> PLUT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE NLY <br /> SE I <br /> PLICATION ACCEPTED BY DATE <br /> kODITIONAL COMMENTS. <br /> PHASE 11 GROUT INSPECTIO PHASE III FINAL INSPECTION <br /> LECTION BY DATE INSPECTION BY DATE <br />