Laserfiche WebLink
~ T SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA- 95205 Permit No. - -i-a <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 3 - - 7.2 <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. <br /> EXACT STREET ADDRESS G C? / <br /> �.-. CITY/TOWN_ <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Name Licensee Phone �;✓7 - -ZJD <br /> IS CERTIFICATE OF WORKMAN'S CO";PENSATION INSURANCE N FILE WITH SJLHD? YES Y0 <br /> TYPE OF WORK (Check) : NEW WELLIX DEEPEN O RECONDITION DESTRUCTION[ G <br /> WELL CHLORINATION Q WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION Q PUMP REPAIR 0 PUMP REPLACEMENT Ea <br /> DISTANCE TO NEAREST: SEPTIC TANK/col* SEWER LINES PIT PRIVY �— <br /> SEWAGE DISPOSAL FIELDf�1�� CESSP L/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. of Well Excavation 12 » <br /> X Domestic/private Drilled Dia. of Well Casing — 19 do '— <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 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump- --- <br /> PUMP <br /> ump PUMP REPLACEMENT: Q State Work Done <br /> PUMP REPAIR: QState Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Prode ure <br />[ hereby certify that I have prepared this application and that the work will be done in accordance <br /> Vith San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local <br /> iealth 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 /> laws of California. <br />[ WILL CALL FOR A GR T SPE PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> iIGNED TITLE: DATE: 46' f J <br /> P L ON REVERSE DE <br />'RASE I R DE?ARTMENT DEPARTMENTUSE ONLY <br /> APPLICATION ACCEPTED BY DATE 1k7 <br />,DDITiONAL COMMENTS: � <br /> at, 2i200&;RK <br /> PHASE II GROUT INSPECTION PHASE III FIA INSP CTION <br /> NSPECTION BY DATE I SPECTION BYDATA <br /> lO <br /> H 14 26 Rev. 9/78 a+� 7 c► J ,x, 17 <br /> -.. ... A <br />