Laserfiche WebLink
44 SAN JOAQUIN LOCAL HEALTH DISTRICT, <br /> `" FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit�No. ./q\ , <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued -Z1� <br /> i <br /> This Permit Ex- ires 1 'Year From Date Issued j <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 /> ,'caquin County Ordinance No. , 1862 and the Rules and Regulations of the San Joaquin Local Health s' <br /> District. <br /> EXACT STREET ADDRESS CITY/TOWN <br /> Owner's Name Phone <br /> Address city. <br /> Contractor's Name '� r � 'License 9 2/_ Phone <br /> i <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO;j INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL Q DEEPEN ❑ RECONDITION ® DESTRUCTION[2 <br /> WELL CHLORINATION Q WELL ABANDONMENT 0 OTHER f- <br /> PUMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS { <br /> Industrial Cable Tool Dia.gof Well Excavation , <br /> Domestic/private Drilled Dia. of Well Casing ' <br /> Domestic/public Driven - Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor i <br /> Type of Pump H..P. l <br /> PUMP REPLACEMENT: [] State Work Dode/ <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter 4F #. Approximate Depth <br /> Describe Material and Procedure <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: a a <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. " <br /> I WILL CALL FOR-,A GROUT rj4qSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> • !:. c.'. FOR DEPARTMENT USE ONLY <br /> PHASE <br /> APPLICATION ACCEPTED BY—Z9DATE <br /> ADDITIONAL COMMENTS: 4 _ <br /> PHASE II GROUT INSP CTION PHAS I I F L INSPECTI N ,+ <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> LEH 1426 ' Rev. 22-77 Y r.�, .;.4 . _.. .. . 1/78 2M <br />