Laserfiche WebLink
' SAN JOAQUIN LOCAL �NEALTH DISTRICT <br /> EOR_Q FFICEarSE: I60I E. Hazelton Ave. ; Stockton, CA 95205 Permit No.� ��y�� <br /> Telephoner (209) 466-6781 r <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date issued �,- - S' <br /> Thi s Permit t Expires res 1 Year Froin`gate. Issued. . ' <br /> Complete In Triplicate <br /> Application is hereby made to the San Joaquin Local Health District for a permit -to construct <br /> and/o'r 'install the work herein described. This. application is made incompliance with San <br />. oanuin 'County Ordinance `No. 1862 and the Rules and Regulations of the San,Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS ' e, 47 X" d CITY/TOWN <br /> Owner' s Name 14(04.? cez, Phone - a -30 <br /> Address aCoQ � �-rLa�'d City <br /> Contractor' s Name&OaZottt� &Aze4_ e/L4/cense# Z,? Phone .74; 8- <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION TINSURAINCE ON FILE WITH SJLHD? YES NO <br /> TYPE .OF WORK (Check): NEW WELL}W DEEPEN ❑ RECONDITION [7 DESTRUCTION[] <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER Q <br /> T PUMP INSTALLATION JET PUMP REPAIR❑ PUMP REPLACEMENT1�j ` <br /> DISTANCE TO NEAREST: SEPTIC TANK /S"6 ° SEWER LINES AOS PIT PRIVY f <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION .SPECIFICATIONS <br /> Industrial . Cable Tool Dia. of Wel,.l., Excavation— <br /> ��Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 2 Com• <br /> Irrigation Gravel Pack Depth of Grout-Seal R J <br /> Cathodic Protection Rotary Type of Grout i <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed b JZ 4 _ <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump N.P. <br /> PUMP REPLACEMENT: Q State Work Done <br /> PUMP REPAIR: QState Work Done <br /> 1 _ <br /> DESTRUCTION OF WELL: Well Diameter Approximate� Depth <br /> Describe Material and Procedure <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 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 : C'o • DATE: If- /.2-78 <br /> (DRAW PL T PL N ON REVERSE IDE <br /> FOR DEPARTMENT USE. ONLY -� <br /> PHASE I <br /> APPLICATION ACCEPTED BY ffL11- R DA E /d/xA_47 <br />'' ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTIO PHAS INSPECTION <br />' INSPECTION BY DATE /a INSPECTION BY DATE ���� <br />