Laserfiche WebLink
r 5AN JUAQUIN LULAL HtALIH U1JI IL <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No._24Q2,,P_J. <br /> Telephone: (209) 466-6781 <br />.. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued- <br /> This Permit Expires 1 YeP-From Date Issued <br /> Complete In Triplicate) <br /> AQplication is4b'ymade to the San Joaquin Local Health District for permit to construct <br /> p Q p <br /> and/or install the work herein described. This application is made in compliance with San <br /> ,'oaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS �2 ( [j > tknaNQ k CITY/TOWN <br /> Owner's Name e" P1 Phone <br /> Address 12 d City FA. <br /> Contractor' s Name }�� � .�--- ��� License#3 4y .3 <br /> PhoneU��-.,3�-� <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELLK 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/SEEPAGE PIT OTHER <br /> PROPERTY LINE --PRIVATE DOMESTIC WELL 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 -3/,q <br /> " <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal h a m r <br /> Cathodic Protection Rotary Type of Grout p,?)Ke_ <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <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 Procedure <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 /> SIGNED TITLE: DATE: 3 1/ q <br /> kUKAW PLOT PLAN ON REVERSE SI <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I , <br /> APPLICATION ACCEPTED BY C/�d DATE <br /> ADDITIONAL COMMENTS: ' <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY <-, , 13 • DATE - 2 J" 2 <br /> EH 1426 Rev. 12-77 1/78 2M <br />