Laserfiche WebLink
F�= -- SAN JOAQUIN LOCA!., HEALTH DISTRICT <br /> FICE USE: 1601 E. Hazelton Ave..; Stockton, CA 95205 [Date <br /> it No. <br /> Telephone: (209) „4.66 -6.781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Issued -!0 <br /> (Complete I-n Tri pl i cate) _ <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 /> 3 District. <br /> EXACT STREET ADDRESS // <br /> 41 <br /> CITY/TOWN <br /> Owner's Name rPhone <br /> Address <br /> Ci ty-: <br /> Contractor's Name License / Phone e"- Z. <br /> IS-CERTIFICATE -OF WORKIItAN'S COMPENSATION, INSURAINCE N .FILE WITH SJLHD? YES No <br />! TYPE Ofi WORK (Check) : NEW WELL QQ DEEPEN 0 RECONDITION [3 DESTRUCTION� T, • . �. <br /> WELL CHLORINATION Q WELL ABANDONMENT,:O - OTHER 0 —� <br /> PUMP INSTALLATION 0 PUMP REPAIR 0 PUMP REPLACEMENT C� S <br /> DISTANCE..TO NEAREST:- SEPTIC TANKSEWER LIMES / PIT PRIVY -�- <br /> y SEWAGE DISPOSAL FIELD/ CESSP 6 <br /> L/SEEPr4GE PIT OTHER- <br /> PROPERTY LINIVN PRIVATE DO ESTIC WEL65622j6_ PUBLIC DOMESTIC WELL -_-- <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 <br /> -� Irrigation =Gravel Pack Depth of Grout Seal T <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 H. . <br /> PUMP REPLACEMENT: ]State Work Done <br /> PUMP REPAIR: Q State Work Done <br /> DESTRUCTION. OF WELL: ' Well Diameter Approximate Depth <br /> Describe Materia an Proce ure <br /> I hereby certify that I have prepared this application and that the work will be done in accordance <br /> with Sart 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 /> x not employ any person in such manner as to become subject to Workman's Compensation <br /> laws of California. " <br /> I WILL CALL R A . OU IN , ION PRIOR TO GROUTING AND`A'FINAL INSPECTION. <br /> SIGNED <br /> TITLE: , DATE://- <br /> W PL N ON REVER SIDE ` <br /> PHASE I - OR DEPARTMEN USE ONLY <br /> MPLICATION ACCEPTED BY <br /> 4DDITIONAL COMMENTS: DATE f vI 7 <br /> PHASE 11 GROUT INSPECT ON <br />:NSPECTIQN �BY PHASE II FINAL INSPECTION' <br /> DATE � ��� INSPECTION <br />:H 14 26 Rev. 9/78 w DATE �' <br />