Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE<4SE: 1601 E. .Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: L.f(209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued _ <br /> d <br /> (Complete in Triplicate) <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 <br /> Joaquin 'County Ordinance No. 1862 and the Rules and' Regulations of the San Joaquin Local Health <br /> District. `.2 c '7 s <br /> EXACT STREET ADDRESSaMIAe. S � � � � <br /> CITY/TOWN <br /> Owner's Name <br /> Phone-23 / !Z133101 <br /> Address <br /> C i ty Awe <br /> Contractor's Name <br /> w License! K/ Phone <br /> IS CERTIFICATE OF WORKMAfid'S CO"€PENSATIOtJ NSURAA,11- ON FILE WITH SJLHD? YES �- <br /> 0 <br /> TYPE OF WORK (Check) : VIEW WELL O DEEPEN O RECONDITION <br /> WE-L-L CHL'' t�INATI�f .L�..,-.._DEOTRUCT,ION.d <br /> w O�','WWELL{'ABANDONMENT,O OTHER(.� <br /> -- PRIMP INS..TALLATION- �-PSP -R.EPA4,RO-2 PllMP''REPLACEMENT,J -�- - - <br /> DISTANCE TO NEAREST: `ySEPTIC-TANK 2 SEWER LINESAkrve PIT"PRIVY <br /> ' SEWAGE- DISPOSAL FIELD �m�t, CESSP L/SEEPAGE PI OTHER <br /> PROPERTY LIN IPRIVATE D MESTIC. WELL^- .--PUBLIC D MESTIC WE <br /> INTENDED IlS ,. TYPE OF-WELL. . CONSTRUCTION SPECIFICATIONS <br /> _In ustrial Cable Tool `D'ia. of Wel Excavation <br /> .`Domestic/private.. <br /> Domestic/publicDrilled Dia, of Well Casing <br /> , e <br /> Irrigation �`' Gravel Pack De Gau g }kof Casing <br /> _Cathodic Protection _ Rotary T pth of Grout Sea <br /> Disposal ype of Grout <br /> =--- -may Other Other Information <br /> z Geophysical ,.. Surface Sea] Insta ed b <br /> PUMP INSTALLATION: 'rCo tractor, , Le a ,L <br /> ,7TYPe of Pump <br /> fjezz H.P. <br /> PUMP REPLACEMENT: QState_WorODone ... � <br /> PUMP REPAIR: OState Work Done,., <br /> DESTRUCTION OF WELL: Well Diameter F <br /> Approximate Depth <br /> tDescribe Materia andPrdce ure <br /> I hereby certify that,-I./have prepared this s app -1 cati on-an.d�that he:work w_i lib°e d"one i n accords <br /> witiSan,`Joaquin]'County....0.rdi.nancei`l,'a te�-Laws;-and-- Ru3�es5and' Reg-5 ations of the San Joaquin Local, <br /> Health 'District. Home owner or ,licensed agent's signature certifies the following: <br /> t"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 /> Taws of California. P <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TIT:REV <br /> : <br /> D L T L ON SE SIDE DATE: <br /> PHASE I R DEA RTMENT USE ONLY <br /> PPLIC TION ACCEPTED BY <br /> 0.DDITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTION <br /> NSPECTTON BY DATE PHA T NA INSPECTION } <br />: <br />:H 14 26 Rev. 9/78 INSPECTION , DATE 4f <br /> 9/78 2M <br />