Laserfiche WebLink
4 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FF E USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit NO. ; <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Ex ares 1 Year From Date Issued <br /> omp ete In Triplicate <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> dnd/or {nstall thework 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 4 9 A G �,� -7�, � 1' o- <br /> Owner's Name CITY/TOWN <br /> Phone <br /> Address—O A L3-r-j- 3 L C1 ty_•�o r <br /> s Contractor's Name_ License# G 2 Phone 1—x'3 <br /> IS CCRTIFICATE OF IJOfY.MAN'S CO"PENSATION INSJRA"!CE ON FILE WITH SJLHD? YES <br /> E <br /> TYPE OF WORK (Check) : NEW WELL 2 DEEPEN O RECONDITION ❑ DESTRUCTION Cj + <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 0 OTHER❑ *14'1 <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT ❑ 1a <br /> DISTANCE TO NEAREST: SEPTIC TANK �S� SEWER LINES Ao" PIT PRIVY <br /> SEWAGE DISP SbL ELD CML/SEEPAGE T— OTHER <br /> PROPERTY LINE -. PRIVATr-WESTIC WELL PUBLI-WESTIC 9n- — i <br /> INTENDED USE TYPE OF WELL <br /> In CONSTRUCTION SPECIFICATIONS <br /> _ ustr a ab a ToolDia. of We�xcavat on ID ow <br /> _Domestic/private Drilled Dia. of Well Casing 6 <br /> Domestic/public Y <br /> Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection (_Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geoph sial Surface Seal Installed <br /> PUMP INSTALLATION: Contractor 5v-. <br /> ' <br /> Type of Pump <br /> PUMP REPLACEMENT: R State Work Done <br /> PUMP REPAIR: ❑State Work Done <br />_DESTRUCTION OF WELL: Well Diameter <br /> Describe Material an rote ure �iproximate Depth <br /> I hereby Certify that I have prepared this application and that the work will be done in accordanc <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 performance of the work for which this permit is issued, I shall 4L 1 <br /> not employ any person in such manner as to become subject to Workman's Compc,nsation <br /> laws of alifornia." <br /> I WILL CAL OR GRO INSPECTI N PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> iIGNED TITLE: �+ <br /> DATE:O^ 7 { <br /> ON REVMZ IDE) <br /> 1HASE I <br /> 7NDMION ACCEPTED BY�. DATE -/7-',� <br /> ADDITIONAL COMMENTS: - <br /> PHASE IT�uf INSPECTION PHASE III FINAL INSPEYE -z <br /> NSPECTION BY DATE INSPECTION BY �- DATf 7 <br /> r <br /> q 1426 • PPv .9-77 1/78 2M ' <br />