Laserfiche WebLink
SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton-.Ave.., Stockton, CA 95205 Permit No. <br /> �= � Telephoner (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This .Perm'it Expires 1 Year From Date Issued <br /> Complete In, Tri plicate . ; <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..,I862. and the Reilys and Regulations of the San Joaquin Local Health <br /> District. <br /> XACT STREET ADDRESS - S CITY/TOWN <br /> r. s ame Phono _ <br /> Address f , <br /> eq- <br /> City <br /> Contractor's NameJi SP ji i(y LicenseL5 Phone S-4Aq--J o% <br /> IS CERTIFICATE OF 1JOPv 1AN'S COMIPENSATIO'N TNSURAINCE ON FILE WITH SJLHD? YES `r NO <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN ❑ RECONDITION <br /> � ❑ DESTRUCTION[1 <br /> R-I-NATION-Q------W-EE"L�_ABANDONMENT p OT-H-R..0 - � <br /> PUMP INSTALLATION � � PUMP REPAIR❑ PUMP REPLACEMENT [� � <br /> DISTANCE TO NEAREST: SEPTI ' <br /> C TANK1 O SEWER LINES •- PIT PRIVY.=;-- . [} <br /> SEWAGE DISPOS FIELD ja CE5SPOOL/SEEPAGE PIT_, - ,d,OTHER -- <br /> PROPERTY LINE rPRIVA E DOMESTI�CEMELL,Ido ' PU.B'LIC ,DOMESTIC WELL — <br /> INTENDED USE TYPE OF' WELL ' <br /> Industrial ' CONSTRl1CTION -SPECiFI TIONS <br /> Cable Tool Dia, of Well Excavation <br /> _Domestic/private Drilled Dia. of Well Casing � <br /> Domestic/public Driven Gauge of Casing s <br /> Irrigation ' <br /> g ' Gravel Pack Depth of Grout Seal p� { <br /> Cathodic Protection Rotary Type of Grout e <br /> Disposal Other <br /> Other Information <br /> Geophysical 1 Surface Seal Installed b <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump_,_ _ - .P. <br /> PUMP REPLACEMENT: ]State Work Done <br /> PUMP REPAIR: QState Work Done ' „mss <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe­Material an Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordance <br /> e <br /> I <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 California. " <br /> I WILL CALL OR A"-.GR 'I PECT.IWN I,OR .T.O. GROUTING AND . <br /> c �FIN_AL NS.PECTION.. , <br /> SIGNED TITLE: _ <br /> DR W PLOT PLAN ON REVERSE SIDE DATE37 ?� <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIO PHASE III FINAL INSPECTION <br /> INSPECTION BY �Z.�J � DATE INSPECTION 8Y DATE <br /> __7-1­� 7,01, <br /> EH-1426 R 12-77 <br />