Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR FFICE USE: 1601 1 lazelton Ave. , Stockton, CA ! )5 JPermit No. 19-? 15 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued G -,2"7-97 <br /> This <br /> 7- <br /> This Permit Exvires 1 Year From Date Issued <br /> (. Complete in Triplicate) <br /> Application 'is hereby made tq the $an Joaquin.'Local Health District for a permit to construct <br /> and/or install the work heren .described: This application is made in compliance with San <br /> Joaquin County Ordinance i1o. 1862. and the Rules and Regulations of the San Joaquin Local Health U <br /> District. <br /> 1103 <br /> EXACT STREET ADDRES � CO, i,..Q. CITY/TOWN <br /> Owner' s Name 9 1�. 2a a Phonea <br /> Address 577 �,��/t� City <br /> Contractor' s ,NameLicense#3 /fav / Phoneg3s�?$-�� <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL O DEEPEN O RECONDITION O DESTRUCTION O <br /> WELL CHLORINATION WELL ABANDONMENT p OTHER O <br /> PUMP INSTALLATION a PUMP REPAIR O PUMP REPLACEMENT O <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSKL FIELD CES�L/SEEPAGE PIS— OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE e ' -TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of, well Excavation <br /> Domes tic/private`: . Drilled r Dia. of Well Casing <br /> Domestic/public ft, 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 /> PUMP INSTALLATION: Contractor � �-_ <br /> Type of Pumper= ��. H.P. <br /> IA- <br /> PUMP REPLACEMENT: O State Work* Done <br /> PUMP REPAIR: OState Work pone <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materia , an Proce ure - <br /> r <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 licefised agent's tignature 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."c i <br /> I WILL CALL FO GROUT'INSPECTTON-PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE:(o--2A—Zg <br /> (DRAW-FLTT-nTN­ ON REVERSE S DE <br /> PHASE I - 'FOR DEP RT USE ONLY <br /> P I TION ACCEPTED BY DATE ^Z S <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BYog!bJ)ATE <br /> 7W 1A9rl pa„ io '77 (971 /7A 9M <br />