Laserfiche WebLink
FOR OFFICE E: 1601 r. Hazelton Ave. , Stockton, CA 952'- Permit No. 7.9 4o <br /> _ Telephone: (209) 466-6781 r <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 3 aZ 9 <br /> This Permit Ex ares 1 Year From Date Issued <br /> omp ete n r p tate <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 /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS d4-3Q-1-1 F MQ/`/R ,Di CITY/TOWN S'70 CX7 K <br /> Owner's Nems OQ.uIA Phone 464-3457 <br /> Address 3D0 E. — /250 S Wil City S"TUC.C? AJ <br /> Contractor's Nam (fLArRJ� k)F(1 Fnu/P LicenseB "A 7 Phone <br /> IS CERTIFICATE OF WORICIAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD7 YES <br /> TYPE OF WORK (Check): NEW WELL DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT❑ OTHER❑ 4 <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT Q # <br /> DISTANCE TO NEAREST: SEPTIC TANK 1401 SEWER LINES PIT PRIVY (� <br /> SEWAGE DISPOSAL-FIELD CUML/SEEPAGE PTT— OTHER <br /> PROPERTY LINE -. PRIVATE-WESTIC WELL PUBLTC-DFESTIC GELS <br /> TENDED USETYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> n us _T strias �61e To Dia. of Well Excavation /Z� <br /> Domestic/private —Drilled Dia. of Weil Casing <br /> Domestic/public —Driven Gauge of Casing /2 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection : kotary Type of Grout <br /> -Disposal Other Other Informal�n <br /> Geophysical Surface Seal Instilled b : <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materia an Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordance <br /> with San Joaquin CoLnty Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local <br /> Health District. Home owner or licensed agent's signature ceetifies the following: <br /> "I certify that in the performance of the work for which this permit is issued, I shall <br /> .ot employ any person in such manner as to become subject to Workman's Compensation <br /> laws of Californ+a." <br /> I WILL CALL FOR A GRObT I SSP TION PRIOR TO GROUTING ATINDD77,((��A��FFI/N(A'L INSPECTION. <br /> SIGNED.- '.O��' � � - UA UNTREVERSTGE) -DATE: 3-I _ <br /> PHASE I FOR UMMENT USE ONLY <br /> ATPl.1"MION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE I GR UT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY 11C/-1 DATE -7 _ INSPECTION BY DATE <br /> EH 1426 Rev. 12-77 <br />