Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH U15IMI - <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.Zg—1kJ a <br /> Telephone: (209) 466-6781 <br /> 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 /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS &P-MILDCITY/TOWN Sr0 CIC rop <br /> Owner's NameT ! 21bf,N�TIJe.� - Phone ?3/-6/6 7 <br /> Address LD City d <br /> Contractor' s Li cense# b 2— Phone <br /> IS CERTIFICATE OF WORKMAN'S. CO"1PENSATIO"l IPtSURA"NCE ON FILE WITH SJLHD? YES ✓ NO <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION 0 DESTRUCTION❑ <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER 0 -C) <br /> PUMP INSTALLATION 0 PUMP REPAIR 0 PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANKJAO�-SEWER LINES I -f PIT PRIVY CIC <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL j <br /> INTENDED USE TYPEWELL CONSTRUCTION SPECIFICATIONS _ <br /> Industrial Cable Tool Dia. of Well Excavation 17." <br /> Domestic/private Drilled Dia. of Well Casing Z" <br /> estic/public Driven Gauge of Casing .� <br /> Irrigation F Gravel Pack Depth of Grout Seal --�► <br /> Cathodic Protection Rotary Type of Grout ---�-� <br /> Disposal fl Other Other Information <br /> Geophysical Surface Seal Instal ed by: <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 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: <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 Cali ria." <br /> I WILL CAL 0 OUT P TION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED 17- TITLE: 100M DATE: as <br /> DRTW PLOT PLAN ON REV SE SiD <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE �� 8 <br /> ADDITIONAL COMMENTS.- <br /> PHASE <br /> OMMENTS:PHASE II GROUT INSPECTION I PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY NI(AA ____ DATE . <br /> EH 1426 Rev. 12-77 1/78 2M <br />