Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> k Telephone: (209) 466-6781 _ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date issued ,/S 4 <br />' (tomplete In Triplicate),' <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct <br /> and/or install- the work herein described. This application is-made -in- compliance with, San ' <br />` JoaquinECoun.ty °Ordinance No. 1862 and the Rules. and Regulations of the San Joaquin 'Local Health <br /> District. <br /> 'EXACT STREET ADDRESS <br /> CITY/TOWN <br /> .Owner's Name _ e . ` . <br /> Phone y <br /> Address .- !4�'+-r ., - ' <br /> C i ty•� <br /> Contractor's Name f License&�2!/I/ Phone_ ' - 7 <br /> f .. <br /> `IS CERTIFICATE 'OF,-WORKt4At4'S-CO""PENSATIOtl-TNSUR •ICE ON',.FIL-£ WiTH`SJLHD?_ SES 0 <br /> TYPE 'OF WORK (Check) : NEW WELL EZ DEEPEN ❑ RECONDITION Q _ DESTRUCTION �. <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ .- OTHER ❑ <br /> r r PUMP INSTALLATION Q PUMP REPAIR❑ PUMP REPLACEMENT Q <br /> DISTANCE TO NEAREST: SEPTIC TANK,�'d SEWER -LINES d �.- „PIT PRIVY <br /> SEWAGE DISPOSAL FIELD ICESSP L/SEEPPGE PIT. OTHER <br /> _ PROPERTY LINE/6-4pRIVATE. DOM STIC WELLS2_L=t_ PUBLIC DOMESTIC WELL . <br /> E' INTENDED USE' TYPE OF WELL } <br /> industrial CONSTRUCTION SPECIFICATTONS <br /> Cable Tool { Dia. of Well Exca.vation <br /> Oomesti c/private Drilled ,Dia-.- of Well Cas i ng s, <br /> Domestic/public Driven Gauge ofiCasing <br /> Irrigation =Gravel Pack Depth of Grout Sea <br /> Cathodic Protection _Rotary Type of-Grout _. y . ,� <br /> Disposal Other <br /> Other Information Irt <br />"_ Geophysical {; Surface Seal InSta ed b <br /> PUMP INSTALLATION: Contractor .' <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: - f <br /> ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter { <br /> Approximate Depth _ <br /> Describe MaterTal and Procedure <br /> z <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 /> 5 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 G OUT SPE T N PRIOR TO GROUTING AND A'FINAL INSPECTION. <br /> SIGNED ' <br /> TITLE: DATE:/s/ ZAff .J� <br /> D PL T PLAN. ON REVERS I E . <br /> 7HA51: I - M OR DEP RTMEN USE ONLY <br /> ^~ <br /> A �PPLICATION ACCEPTED BY � DATE S� G. 9` <br />%DDITIONA[: COMMENTS: <br /> PHASE II GROUT INSPECTION IPHASE III FINAL INSPECTTON <br /> NSPECTION, BY DATE 2/ INSPECTION BY DATEf <br />:H 14 26 Rev._9/78 /x/ <br />