Laserfiche WebLink
SAN JUAQU1N LUCAL HtALIH U15IKlLI <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No-7g,-,133,- <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued--f-,;7-2B,' <br /> This Permit Expires I Year From Date Issued <br /> 1 ete <br /> In Triplicate <br /> Dplication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> yid/or install the work herein described. This application is made in compliance with San <br /> oaouin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> S t t J►-►..` A/- of 1/A N4 41-L6" 5c�4�v L <br /> lI i? <br /> XA _ JDRES C3 ,y L• Sic�� CITYf TOWN ZSC'/tka:v <br /> aner' s Name FR AAa .2,4 A-..fcA Phone og? - -?11 <br /> caress 2 4S3 2 A- City 4SC/a4cJ <br /> ontractor' s Name ', �,��, ��j„� License#,277810 Phone 63,9-.2-2o-7 <br /> S CERTTFTCRTE OF WORKMN 'S CO}'PENSATIOIN INSURA"10E ON FILE WITH SJLHD? . YES X NO <br /> YPE OF WORK (Check) : NEW WELL C7 DEEPEN O RECONDITION [J DESTRUCTION❑ - - -- <br /> ,-- WELL CHLORINATION ❑ WELL ABANDONMENT 0 OTHER 0 ; <br /> PUMP INSTALLATION (3. PUMP REPAIRL3 PUMP REPLACEMENT ❑ <br /> ISTANCE TO NEAREST: ,, SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISP S�AL FIELD" ` CESSP L/SEEPAGE .PIT— OTHER <br /> PROPERTY LINE - PRIVATE D MESTIC '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 Driven Gauge 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 by: <br /> UMP INSTALLATION: Contractor T-d7, <br /> Type of Pump �S H.P. / <br /> UMP REPLACEMENT: [) State Work Done <br /> UMP REPAIR: O State Work Done <br /> ON LL <br /> ESTRUCTIOF WE : Well Diameter Approximate Depth <br /> 'Describ6 'Material and Procedure <br /> t <br /> hereby certify that I have prepared this application and that the work will be done in accordar <br /> ith San Joaquin County Ordinances , State-.Laws , and Rules and Regulations of the San Joaquin Loce <br /> ealth 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 in such manner as to become subject to Workman's -Compensation <br /> laws of California." <br /> WILL CALL FOR A GROUT I PECTION •PRIOR.,TO GROUTING AND A FINAW INSPECTION. <br /> IGNED �s r_ :TITLE: DATE: �cS��7C7 <br /> DR L -'-ON REVERSESIDE <br /> �F:OR . EPA TME•NT. <br /> . <br /> HASE I _USE ONLY <br /> PPLICATION ACCEPTED BY _'�:" 4L.4DATE <br /> DDITIONAL COMMENTS: <br /> PHASE .II GROUT INSPECTIOU. PHASE I WaFINAL INSPECTION <br /> VSPECTION BY ,, ' DATE INSPECTION BY& DATE4/Z-7X <br />