Laserfiche WebLink
� t- SAN JOAQUIN LOCAL HEALTH DISTRICT ! <br /> J,,�:_:Q?UEFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No."2 ',:�77 Fa <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> (Complete In Triplicate) <br /> ck5w- 07 0 nl I <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 /> E District. <br /> EXACT STREET ADDRESS ` d; <br /> k1 "fes reit e► d �.t CITY/TOWN <br /> Owner's Name <br /> � Phone <br /> Address- Y <br /> ! Cit <br /> Contractor' s Name License# l <br /> 93 7 Phone L — C 7 L <br /> f IS CERTIFICATE OF 140RIMIAN'S COM E"!S TIOiI IPISURANCE ON FILE WITH SJLHD? . YES NO i <br /> TYPE OF ORK (Check) : NEW' WELL L DEEPEN0 M�RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATIONDNTP <br /> PUMP INSTALLATION Q PUMP REPAIRC@ UMP I <br /> REPLACEMENT <br /> ISTANCE 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 I V <br /> INTENDED USE TYPE OF WELL <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia. of Well Excavation <br /> __�' Domestic/private Drilled Dia. of Well Casing <br /> _Domestic/public Driven Gauge of .Casing - <br /> Irrigation .7—Driven <br /> Pack Depth of Grout Seal <br /> Cathodic Protection Rotar <br />°Disposal y Type of Grout <br /> other Other Information J <br /> Geophysical Surface Seal Installed b : w: <br /> PUMP INSTALLATION: Contractor <br /> Type of-Pump , <br /> _R_-P t Y <br /> PUMP' REPLACEMENT: 0 State Work Done <br /> PUMP REPAIR: XState Work Done <br /> DESTRUCTION OF WELL: .,. Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> ` r <br /> I hereby certify that I have prepared this application and that the work will be done in accordant <br /> wi'th .San. Joaquin County Ordinances ,. State Laws , and Rules and Regulations of the San Joaquin Local <br /> Health District. Home owner or lice <br /> "I nsed agent's signature certifies the following: <br /> certify that in the performance of the work for which this { <br /> not er6ploy any person in such manner as to become subject to Workman's Compensation <br /> I <br /> laws of -California .." <br /> I WILL CALL- FOR A GROUT INSPECTIO PR 0 GROUTING AND A FINAL INSPECTION. <br /> SIGNEDTLE: r DRTE: <br /> ` W PP- 1 PL N N REVERSE SIDE <br /> PHASE I FOR DEPARTMENT SE ONLY <br /> APPLICATION ACCEPTED BY DATE z <br /> ADDITIONAL COMMENTS : <br /> PHASE II GR1-7 <br /> OUT INSPECTION <br /> INSPECTION BY PHASE III FINAL INSPECTION � <br />` DATE INSPECTION BY <br /> LH 14 26 Rev. 9178 _ - _,�____ DATE y <br /> 5 9 2M ` <br />