Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT - - <br /> FOR FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 7:2_5-"6 <br /> Tele,,; (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued _7 <br /> This Permit Expires 1 Year From Date Issued <br /> Ile Complete In Triplicate <br /> Application is her 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 /> Q <br /> District. 3qG ` sacc - o "7- con/C-r CA.J <br /> CA <br /> EXACT STREET ADDRESS �Z1> CITY/TOWN 19�CAA,"Ir <br /> Owner's Name Phone <br /> Address I R(C� h C i ty L ,,r <br /> tt <br /> / _-.Phone?�� 3 <br /> Contractor's Name �j �.�"�� u��tC��,E'ftti,tfE� License#��7E�� �_ 3 <br /> IS CERTIFICATE OF WORKMAN'S COIA"PENSATIO'N INSURAINCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEWtWELL;4 DEEPEN_0 RECONDITION r7l DESTRUCTION E:1 <br /> WELL. CHLORINATION p WELL ABANDONMENT ® OTHER 0 - __— <br /> PUMP INSTALLATION Q PUMP REPAIR 0 PUMP REPLACEMENT ( <br /> DISTANCE TO NEAREST: SEPTIC TANK jt?r/SEWER LINES lefef PIT PRIVY <br /> SEWAGE DISPOSAL FIELD-t�^- ESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE-�C PRIVATE DOMESTIC WELL � PUBLIC DOMESTIC WELL= �� <br /> INTENDED USE TYPE OF WELL r CONSTRUCTION SPECIFICATIONS <br /> Industrial X Cable Tool Dia. of Well Excavation lzp <br /> Domestic/private Drilled Dia. of Well Casing Z4-- � <br /> Domestic/public Driven Gauge of Casing �lr <br /> _Irrigation Gravel Pack Depth of Grout Seal <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.P. <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION- OF WELL: Well Diameter.' Approximate Depth <br /> Describe Material and Proce ure <br /> I hereby certify that I have prepared this application and that the work will be done in accordant <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 FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNEDt 1 �- - TITLE: DATE: <br /> (DRAW PL T PLAN ON REVERSE SIDE) � �` <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY' DATE <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 11/4f 7 <br /> EH 14 - '� r 1/78 2M <br />