Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. Z <br /> ,. l..S— 6 <br /> Telephone: (209)' 46.6-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Expires 1 Year From,Cate Issued w <br /> Complete In Triplicate <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. 1862 and the Rules and Regulations of the San Joaquin Local, Health <br /> District.. <br /> EXACT STREET ADDRESS 3 (,v CITY/TOWN <br /> Owner's Name Phone <br /> Address 2-2 4,z City <br /> Contractor's Name 4D P License# Phone <br /> IS CERTIFICATE OF WORK'iAN'S COFr1P£NSATIO'! I'ISURA"f'CE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION '0- DESTRUCTION[r ""' <br /> WELL CHLORiNATION ❑ WELL ABANDONMENT 0 OTHER ❑ � <br /> / PUMP INSTALLATION ❑ PUMP REPAIR. PUMP REPLACEMENT ❑ <br /> DISTANCE.-TO--NEAREST.----,SE-PTIG TANK-, --f----SEWE-R-LINES-'- .- .PIT RRIVY", �-,� . -_ x -60 <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER r <br /> PROPERTY LINE -, PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE 'OF`WELL ~'� ""� " —CONSTRUCTI-ON SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <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 by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP -REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: RfState Work Dane <br /> DESTRUCTION OF WELL: WelliDiameter 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 accordance__ <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 CALLAR I GROUT WSPECTION P IOR TO GROUTING AND A4INAL INSPECTION. # <br /> SIGNED TITLE: ATE: ' <br /> W PLOT FL-9-N- ON RE•V.ERSE SID <br /> PHASE I FOR DEPARTMENT USE 'ONLY <br /> APPLICATION ACCEPTED BY DATE f� �? <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III F NAL INSPECTION ' <br /> INSPECTION BY . _ DATE INSPECTION BY DATE <br /> F <br /> EH 1426 Rev- 12-7-1_.. __ ��� 1 /7R 7M <br />