Laserfiche WebLink
SAN JOAQUIN ,LOCAL HLALIH UISIHICI <br /> FFICE USE: 1601 E lazelton Ave. , Stockton, CA S 15 Permit No. `7 9-7 0 / <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued -� -7 <br /> This Permit Expires 1 Year From Date Issued <br /> (Complete in Trip icate" <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described.- This application is made in compliance with San u` <br /> Joaouin County Ordinance 114o,, 1862 and the Rules and Ret}ulations of the San Joaquin Local Health <br /> District. �� <br /> EXACT STREET ADDRESS 3Z/ C,_) i� CITY/TOWN <br /> Owner's Name <br /> AddressoZ� c.� G! "" City <br /> Contractor' s Name �(ai u;� License; 7/ PhoneFX:;_-S£s-/T— <br /> IS_CERTIFICATE OF WORKMAN'S COMPENSATIO ! INSURANCE ON FILE WITH SJLHD? YES^j NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ , "RECONDITION[] — DESTRUCTION❑ <br /> WELL CHLORINATION Q WELL ABANDONMENT 0 OTHER 0 <br /> PUMP JNSTALLATION ( PUMP REPAIR 0 PUMP REPLACEMENT ❑ G <br />•DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 'PIT PRIVY <br /> SEWAGE DISP SEAL FIELD CESSPOOL/SEEPAGE I — OTHER <br /> PROPERTY LINE -. PRIVATE D MESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE r' TYPE OF WELL • CONSTRUCTION SPECIFICATIONS �I <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/privateDrilled: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 /t <br /> Disposal —Other, Other Information <br /> Geophysical Surface Seal Installed by: <br />(PUMP INSTALLATION: Contractor. <br /> Type of Pump � c,G- H.P. z _ <br /> PUMP REPLACEMENT: FIS tate_;Work Done <br /> PUMP REPAIR: ❑State Work Done _ <br />)ESTRUCTION 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 /> Frith San Joaquin County Ordinances , State Laws, and Rules and Regulations of the San Joaquin Local <br /> 4ealth 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 '.becom2 subject to Workman's Compensation <br /> laws of California." ` ,. <br /> WILL CALLFGK A,GROUT INSPECTION *PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> iIGNE TITLE: DATE: ? <br />_ tZDRAW PLOT PEW ON REVER E SIDE <br /> CHASE I FOR DEP T USEONLY <br /> kPP—LOTION ACCEPTED B ho DATE,-p"�5�-��� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> NSPECTION BY -DATE INSPECTION BY C <br /> IJ tAn.0 n_.. In ,, <br />