Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTW DISTRICT <br /> Stockton, CA 95205 LPermi t No. ` -EOR FFICE USE: 1601 E. Hazelton Ave. ,Telephone: (209) X466-6781 Issued 7-//-'7 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit Expires 1 Year From Date Issued <br /> Complete In Triplicate <br /> Application is hereby made -to the San Joaquin Local Health District orca permi <br /> liancetwith nSan <br /> uct <br /> and/or install the work herein described. This application is m compliance <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> CITY/TOWN G`�G <br /> EXACT STREET ADDRESS1 - <br /> . .__ .� <br /> u h Y Phone <br /> Owner's Name _ <br /> Address W w City � c <br /> Contractor' s Name e <br /> s License Phone <br /> I5 CERTIFICATE OF WORKMAN'SC01,1PENSATIO'I I�dSURAINCE ON FILE WITH SJLHD? YES NO <br />` TYPE OF WORK (Check) : NEW WELL 0 DEEPEN ❑ RECONDITION C] DESTRUCTIOWELL N <br /> 0 OTHER <br /> WELL CHLORINATION C3PUMP INSTALLATION Q PUMP REPA�RNC7 NTPUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY OTHER <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL R, <br /> - TYPE�OFMWELL CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE — -- <br /> Industrial Cable Tool Dia: of Well Excavation <br /> Domestic/private DrilledDia. 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 <br /> Disposal Other Other .Information <br /> Geophysical Surface Seal Installed by: <br /> ' PUMP INSTALLATION: Contractor �a <br /> Type of Pump i , H.P. <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: a ❑State Work Done ._ _ <br /> DESTRUCTION OF WELL: . Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify thatI_hav_e prepared this application and that the work will be done in accord'a c <br /> with San Joaquin County Ordinances , State--L-aws-,-..and_, ul es 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 /> k laws of California." <br /> I WILL C FORA GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: �T 7�Z <br /> DRAW PLOT PL N ON REVERSE SIDE <br /> FOR DEPART E ONLY Al <br /> PHASE I DATE —7 <br /> , APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE III F NAL INSPECTION <br /> PHASE II GROUT INSPECTION <br /> INSPECTION BY <br /> INSPECTION BY DATE <br />