Laserfiche WebLink
5 <br /> SAN JOAQUIN LOCAL- HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. _S <br /> Telephone: (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> F <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, wor'k hereindescribed. This application is made in compliance with San <br />,'oaquin County _Ordinance "io. .1862 and the Rules and Regulations of the San Joaquin Local Health <br />�i5trc1C. f ; <br /> EXACT STREET ADDRESS`. `"GG/ � i��'4/(? C� �r�. _ �'_ CITY/TOWNot�� <br /> Owner's Name Phone RY% <br /> Address ;V.1_101 C��3T r/� City S/mac ✓��'/ <br /> Contractor's Name - <br /> .�� License# Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO'J INSURANCE ON FILE WITH SJLHD? ? YES 1110 <br /> TYPE OF WORK (Check): NEW WELL DEEPEN 0 RECONDITION C3 DESTRUCTION❑ <br /> WELL CHLORINATION 0 WELL ABANDONMENT p OTHER❑ 'S11 <br /> PUMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT ❑ NJ <br /> DISTANCE TO NEAREST: SEPTIC TANKAAV SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATF DOMESTIC WELL.�� PUBLIC DOMESTIC WELL V <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS` <br /> hndustrial - Cable Tool Dia. of Well Excavation <br /> Domestic/private, Drilled„ . Dia. of Well .Cas_ing rr <br /> Domestic/public Driven - Gauge of Casing <br /> IrrigationGravel Pack Depth of Grout lea <br /> Cathodic Protection Rotary Type of Grout Z7 dmirz •-- <br /> Disposal Other Other Information <br /> Geophysical k Surface Seal Installed by: ',�g,u�c, CcJ c� <br /> PUMP INSTALLATION: Contractor Z2,,2 z Zi e �`�`` <br /> .�c_ Com. <br /> Type 'of J Pump H. 5' <br /> PUMP REPLACEMENT: Q State Work Done . 1 <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 <br /> Prepared this application and that the work will be done in accordance <br /> Nith San Joaquin County Ordinances, State :Laws, and Rules and Regulations of the San Joaquin Localk <br /> iiealth 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 />[ WILL -CALL -FORA C3ROUT SPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: <br /> W PLOT PL N ON RE RSE SIDE <br /> FOR DEPARTMENT USE ONLY ' <br /> 1.HASE I <br /> VPPLICATION" ACCEPTED BY DATE a I 7 <br /> kDDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE, II14F <br /> XNAL IfSPECTI N <br /> NSPECTION BY DATE INSPECTION BY DATE <br />.H 1426 Rpv_ 19-77 �'/7 17Q 1)M <br />