Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH UISFRICI--FOR OFFICE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. �4 -o? <br /> « - 02-- Telephone: (209) 466-6781 ,/� ,� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Expires 1 Year From Date Issued <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 />,'oaauin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS CITY/TOWN <br /> Owner' s Name J � Phone <br /> Address City <br /> Contractor's Name — License#,,JPhone <br /> IS CERTIFICATE OF WO IAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES NO X <br /> TYPE OF WORK (Check) : NEW WELL D DEEPEN 51 RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT D OTHER D -J <br /> PUMP INSTALLATION ❑ PUMP REPAIR D PUMP REPLACEMENT ❑ 1J <br /> DISTANCE TO NEAREST: SEPTIC TANKIER 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 /> IndustrialCable Tool Dia. of Well Excavation W <br /> Domestic/private Drilled Dia. of Well Casing /Z If <br /> Domestic/public Driven - Gauge of Casing <br /> ,l 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 H.P. <br /> PUMP REPLACEME��#T'% � [7State Work Done <br /> a. :? S <br />&? MP 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 accordance <br /> with San Joaquinv 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 CAW FOR ROUT IN ECTION PRIOR TO GROUTING AND A FINAL INSPIECTION. <br /> SIGNED TITLE: DATE:'/ <br /> DRAWsPLOT PLAN ON REVERSE SIDE <br /> 49 <br /> rzFOR DEPARTMENT USE ONLY <br /> PHASE�7-1 <br /> APPLICATION ACCEPTED BY_ p DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE_ I.IV FI y1L INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> EH 1426 Re 1/78 2M <br />