Laserfiche WebLink
SAN JUAQU1N LUCAL HLALIH U15IKILI <br /> r FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 7f_ <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued 3-Zd-7f <br /> This Permit Expires 1 Year From Date Issued. <br /> ` Complete In Triplicate <br /> 2 <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> anal/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 /> 0 <br /> EXACT STREET ADDRfSS�� (OC)& - E.D A (' P C4 CITY/TOWN c� <br /> Owner's Name <br /> Phone 3Y i <br /> Address i,6/�- 1, CN City <br /> Contractor' s NameiA�,,� -.i-. Li cense#e3,+or1 qV Phone I-�,��'� <br /> IS CERTiF'ICATE OF WORKMAN'S COMPENSATIOIN INSURANCE ON FILE WITH SJLHD? YES IJO <br /> TYPE OF WORK (Check) : NEW WELL($ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION 0 WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/�EPA,GE PIT OTHER <br /> PROPERTY LINE --PRIVATE DOMESTIC WELL.0'=— PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial _Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing jam; _ <br /> Domestic/public Driven Gauge of Casing <br /> _Irrigation Gravel Pack Depth of Grout Seal M '+er_ <br /> Cathodic Protection Rotary Type of Grout " P_ <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: E]State Work Done <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 prepared this application and that the work will be done in accordanc <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 /> SIGNED TITLE: DATE: <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY C. DATE �f�s �7J� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 2_3 7? <br /> EH 1426 Rev. 12-77 1/78 2M <br />