Laserfiche WebLink
4 <br /> / d SAN JOAQUIN LOCAL;'HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave, ,. Stockton-, CA 95205 Permit No. 7q - <br /> Telephone:. . (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued ( 7 <br /> q. <br /> 4� i 2 b ? '(Complete In Tri p1 i tato) <br /> Application is hereby made to the San Joaquin Local Health"Pi strict for a permit to construct <br /> and/or install the work herein descri-bed. This app,li.cat.ioh, 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 AY, Coy- w CITY/TOWN ? <br /> Owner'.s Name A, <br /> 1 d Phone <br />' <br /> Address- <br /> Contractor's <br /> ddress-Contractor's Name SVV.4.) License# X23 7xx"Phone . 74 2!,6 _ <br /> IS CERTIFICATE OF WORKMAN'S &.1 NSATION INSURAINCE ON FI[ [ WITH SJLHD? YES 0 <br /> ,TYPE OF WORK (Check) : NEW WELL 0 - :.,AEEPEN 0 RECONDITION DESTRUCTION 0 _ <br /> WELL CHLORINATION Q - WELL-ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION 0 PUMP REPAIR O PUMP REPLACEMENT Q <br /> DISTANCE TO -NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD .- CMP L/SEEPAGEPte- OTHER. <br /> PROPERTY LINE .- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS - <br /> Industrial Cable Tool Dia.. of Well Excavation <br /> :Domestic%private Drilled Dia. of Well Casing <br /> Domestic/public DrivenGauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal _ Other Other 'Information <br /> Geophysical Surface Seal Installed <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: p State Mork Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF-WELL: Well: Diameter Approximate Depth . <br /> Describe Material and Proce ure <br /> I hereby certify that I have ,prepared' this application and that the work Will be done in accordance <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 <br /> not employ o <br /> p y an y person in such manner as to become subject to Workman's Compensation - <br /> laws of California. <br /> I WILL -CAL . FOR.A GROUT -INSPEON PRIOR 0 GROUTING ANDA FINAL INSPECTION. <br /> SIGNE ITLE: DATE: H 3d <br /> LOT L ON REVERSE SIDE <br /> PHASE i <br /> P FOR DEP TMEN USE ONLY !1 0 <br /> y ���w� <br /> APPLICATION ACCEPTED BY DATE G' 111Z? <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT- INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION, BY DATE INSPECTION BY DATE <br /> EH 14 26 ,Rev. 9/78 g - _g 117$. , <br />