Laserfiche WebLink
r SAN JUAQU1N ,LUCAL HtALIH U1JIKMI <br /> FFICE USE: J601 E. Hazelton Ave. , .Stockton, CA 95205 Permit No. <br /> Telephone:, (209) 466-6781 <br /> f, APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Expires I Year From Date Issued <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 /> . oaquin County Ordinance No. 1862 and -the Rules and Regulations of the Sari Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS_/ e,L '¢ CITY/TOWN , SGeIJ _ <br /> Q ner' s Nance ��. L �y�r� Phone�j��p=o2��- <br /> -- <br /> Address r,, City� e A) <br /> Contractor's Name r 5� ;Y. Licensei2NAe) Phone <br /> 'S CERTTF"ICATE OF WORKMAN'S 011PENSATIO"1 I"3SUfiA" C'E—ON FILE-WITfI-SJLHD? YES NO <br /> TYPE_ OF WORK (Check) : NEW WELL 0 DEEPEN O RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION 0 WELL ABANDONMENT ED -OTHER ❑ <br /> PUMP INSTALLATION Q PUMP REPAIRA1 . PUMPaREPLACEMENT 0 � <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY ` . <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT-1... -,1 OTHER (� <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL - PUBLIC DOMESTIC WELL ch <br /> INTENDED USE TYPE OF WELL 'CONSTRUCTION SPECIFICATIONS <br /> Industrial _ Cable-'T-0-0'1--'— --° Dia.--of-Well Excavation <br /> Domestic/private -Drilledl '=� 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 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT:. ❑ State WorkDone <br /> t <br /> R PUMP REPAIR: WState Work Done „l _ <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> K <br /> 1 <br /> { I hereby certify that I have prepared this application and that the work will be done in accordan <br /> with San Joaquin County Ordinances , State Laws , ` and .Rules and Regulations of the San Joaquin Loca <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 shal-1 <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 IN ECT ON PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE; DATE. / <br /> r <br /> (DRAW PIOT PLTN ON REVERSE SIDE <br /> FOR DEPART ENT USE ONLY <br /> PHASE I E <br /> APPLICATION ACCEPTED BY DATE 7 <br /> /79, <br /> ADDITIONAL COMMENTS: ` s <br /> PHASE II GROU T INSPECTIOW HASE III FINAL L.NSPECTION <br /> ` INSPECTION BY DATE INSPECTION B - DATE"` " <br /> EH 1426 Rev- 12177 /78. 2M <br />