Laserfiche WebLink
;' - .P'MMW^_r.+.,._.-.n..t.:.,a..v,.T.r+n.:.-Te Rr n+nr--reo�..',.n �,..,....., .....:n ..-..:,a,rn w,'n..:-,c,..,s,,......... .. _.___........ -<.-•'"M'rd?ri4ti <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FF CE USE: 1 1601 E. Hazelton Ave. , Stockton, CA 95205 <br /> JPerynit No.l <br /> Telephone: (209) 466-6781 <br /> > 5 APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued G < -7 <br /> This Permit Ex fres 1 Year From Date Issued <br /> ^ " Comn ete n rip icate <br /> , , Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> ' '-,', Application <br /> and/or install the work herein described. This application is made in compliance with Sar. <br /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> ` " ..District. /f <br /> d u ;EXACT STREET. ADDRESS _�Oj j So �J9 �WV CITY/TOWN froe-' C e" <br /> r Owner's tame, <3i - Phone <br /> ` Address _ �- Citi <br /> Cnntractor's Name LicenseV,L0212r- Phoney/-Z44- <br /> 22 i <br /> ,y9 IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD7 YES tJ0 x, <br /> n TYPE OF WORK (Check) : NEW WELL❑ DEEPEN❑ RECONDITION DESTRUCTION❑ i <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR 0 PUMP REPLACEMENTJ�J i <br /> DISTANCE TO NEAREST: SEPTIC TANK Ila SEWER LINES1�U PIT PRIVY i <br /> { SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE P3f— OTHER 1 <br /> PROPERTY LINE -. PRIVATE WELL PUBLIC DOMESTIC <br /> —� <br /> y INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ti <br /> ustria _ able Tool Dia. of We Excavation _ R <br /> Domestic/private Drilled Dia. of Well Casing <br /> Y; Domestic/public Driven - Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> 3.: Cathodic Protection Rotary Type cf GroutT <br /> ^� Disposal _Other Other Information ; <br /> C*M*ysICaI Surface Seal Installed by : <br /> PUMP INSTALLATION: Contractor 4�1f�. 17— <br /> Type <br /> Type of Pump --- Ham. <br /> cy?;. PUMP REPLACEMENT: 0 State Work Done <br /> PUMP REPA;R: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materia an Croce urd- e <br /> r <br /> ` I hereby certify that I have prepared this application and that the work will be done in accordance; <br /> 't 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 /> V not employ any person in such manner as to become subject to Workman's Compensation <br /> laws of California." <br /> ) I WILL CALL FOR A_GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: i= �/� DATE: <br /> 7� / Z Y <br /> �� W L T-PUW ON REVERS IDE <br /> - - <br /> , <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> WlDATION ACCEPTED BY Cie DATE A6 -7'%- /75 <br /> ADDITIONAL COMMENTS: <br /> _- PHASE II ROUT INSPECTION PHASE III FINAL INSPECTION <br /> ?s: €INSPECTION BY DATE INSPECTION BY fes- DATE Z/ <br /> r EH 1426 Rev. 12-77 1/78 2M <br />