Laserfiche WebLink
SAN JUAQUIN LOCAL -HEALTH MIRICf <br /> OFFICE USE: 1601 E. Hazelton Ave, , Stockton, CA 95205 Permit No. _3 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 3 This Permit Expires 1. Year From Date .Issued <br /> Complete In Tri pl i cate <br /> Application is hereby made to the San Jaaqui-n Local Health District for a permit .to construct <br /> and/or install the work herein described. - This application is.made in compliance wi-th San ,, <br /> Coaquin County Ordinance No. 1862 and .the Rules and. Regul.ations of the San Joaquin Local- Health <br /> District. � <br /> EXACT STREE RESS � i4 CITY/TOWN <br /> Owner' s Name - f Phone <br /> Address <br /> City <br /> Contractor's Name License# Phone _d <br /> IS CERTIFICATE OF WORKHAN'S COMPENSATMI' TH41PA110E ON FILE WITH'SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELQV DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ GJ 4" <br /> WELL CHLORINATION 0 WELL ABANDONMENT ❑ OTHER 0 <br /> PUMP INSTALLATIONPUMP REPAIR❑ PUMP REPLACEMENT p <br /> DISTANCE TO NEAREST: SEPTIC TANK 63— SEWER LINES. PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/S,�.�PA&E PIT N., OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL 'yyPUBLIC 00MESTICWELL 1� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial i Cable Tool Dia. of Well Excavation <br /> Qomestic/private Drilled Dia. of Well Casing <br /> Domesti-c/public Driven Gauge .of,Casin`g� 19 -' <br /> Irrigation 1 Gravel Pack Depth of Grout .Seal <br /> Cathodic Protection t Rotary Type of- Grout <br /> Disposal' . Other �€�'=Other" Information' a .e/F <br /> Geophysical f ��• Surface Seal Instal[ ed s <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br />( PUMP REPLACEMENT: State Work Done <br /> � <br /> ❑ � a <br /> PUMP REPAIR: ❑StateiWork Done - � <br /> DESTRUCTION, OF WELL: Well Diamete,r` —AP prox-i mate-_Qepth.�'- <br />{` Describe+Materia and Procedure ��"� � 1% <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 Ru les 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 Calif " <br /> I FOR GM SP MON PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED } TITLE: cx DATE: <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEP RTMENT USE ONLY <br /> PHASE I <br /> APPLICATION :ACCEPTED BY � DATE ' 7� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> ! INSPECTION BY DATE --?. 7A INSPECTION BY DATE :- <br /> EH 1426" Rev_ 12-77 "'1/78 2M <br />