Laserfiche WebLink
Y' SAN JOAQUINILOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. -- 12 <br /> : - �(20f <br /> � <br /> Telephone <br /> 9) �466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date issued / <br /> -� <br /> ( ornplete 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 CITY/TOWN .�iu Jam <br /> 'Owner's Name 2-.. l Phone EW 7 3 /?0E— <br /> fCity ,/-Address � <br /> Contractor's Name License#� Phoneme <br /> ` IS CERT.TFICATE OF WORKMAWS4,01MPENSATION INSURA"ICE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN 0 RECONDITION ® DESTRUCTION <br /> WELL CHL R NATION 0 WELL ABANDONMENT 0 OTHER 0 � <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT ❑ CII <br /> ' -DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES D.... "PIT PRIVY �- <br /> t SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLTC DOMESTIC WELL T <br /> - r <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS C <br /> Industrial Cable Tool Dia. of Well Excavation . <br /> Domestic/private Drilled Dia, of Wel ] Casin <br /> — _ - Domestic/public-- Driven _ � Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout / c�T <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor Y.,4 ' <br /> Type of Pum H.P. C--- <br /> PUMP REPLACEMENT: .Q State Work Done <br /> 'UMP 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 accordanc <br /> with San Joaquin- .County Ordi-nances, State Laws , and Rules and Regulations of- th'e- San Joaquin-Local <br /> 1iealth' District. Home owner or licensed agent' s signature certifies the following: <br /> t "I certify' that in the performance of the work for which this permit is issued, I shall <br /> not em toy erson in such manner as to become subject to Workman's Compensation <br /> k la o C iforn*a. <br /> WILL CALL F R A.G UT INSPECTION PRIOR TO GROUTING AND A"FINAL IN$PECTION. /�Jr{� <br /> - .--,Sr f fI <br /> � SIGN£D TITLE: DATE: <br /> DR L N ON REV S SIDE <br /> ' FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ZLZ DATE <br /> . ADDITIONAL COMMENTS: <br /> ' PHASE II GROUT TNSP£C1'ION PHASE TII FINAL INSPECTIO <br /> ` INSPECTION BY DATE 0 TNSP CTION BY \ DATE C1 <br /> EH 14 26 Rev. "9/78 `— s .��. _ - c�-�- 9/78" 2M - <br />