Laserfiche WebLink
SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FQS-OFFICE USE: 1601 E. Hazelton Ave: , Stockton, CA 95205 Permit No._7 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued —/-78" <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 for a permit to construct <br /> and/or install the work herein described. This, application is made in compliance with San f <br /> Joaquin ;County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS `,s1: 05qlCITY/TOWN j <br /> Owner's Name Phone <br /> Address 01._V City -r, <br /> Contractor's NameC2,,2License# d), Phone67,5-17 <br /> IS CERTIFICATE OF WORKMAN'S CO"iPENS Tn ItdSURA?ICE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL M A DEEPEN ❑ RECONDITION ❑ DESTRUCTION[:] j <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENTI� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY G <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> y PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL v <br /> INTENDED USE TYPE OF .WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> —Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 1/40 <br /> s <br /> Irrigation Gravel Pack Depth of Grout Seal 66-0 <br /> } <br /> Cathodic Protection =Rbtary Type of Grout o E1'f� <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: 7 <br /> PUMP. INSTALLATION: Contractor <br /> Type of Pump H.P. <br />.PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth. <br /> Describe Material and Procedure <br /> I hereby certify that I 'have prepared this application andthat the work will be done in accordance; <br /> with San JoaquinfCounty 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:- <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 /> 1 WILL C FORA GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE:: <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I• FOR DEPARTMENT USE ONLY <br /> APPLICATION,.,ACCEPTED BY . DATE -7(f <br /> i <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY� / DATE , ,, INSPECTION BY �l9. DATE <br />