Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FF CE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6781 -/ <br /> CONSTRUCTION OR PUMP PERMIT Date Issued Y` /�''� <br /> ----. APPLICATION FOR WELL <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 /> - <br /> EXACT STREET ADDRESSS CC�C� /z CITY/TOWNS„ Joc _ <br /> Owner's Name LAUD r' aZz Z -4 V,12 Phone <br /> Address 2 / Al. &,q ZI- City <br /> Contractor's Name_IoLicense# , _ Phone g��b <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSUR CE ON FILE WITH SJLHD? YES -_ gt N0 <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN 96 RECONDITION ❑ DESTRUCTION rl <br /> WELL CHLORINATION © WELL ABANDONMENT 0 OTHER[3 �...--.—• <br /> PUMP INSTALLATION Q PUMP REPAIR OPUMP REPLACEMENT L3 a <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESSI PIT PRIVY <br /> SEWAGE DISP SALE IELD_�'Q .� CESSPWL/SEEPAGE PIT ---- OTHER -- <br /> PROPERTY LINRa 4PRIVATE DOMESTIC WELL i=-L-- - PUBLIC DOMESTIC WELL -�- <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industria Cable Tool Dia. of We 1 Excavation ` ,s (% <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing � <br /> I rri gati on Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout ti <br /> Disposal Other Other Informaon—T1 <br /> Geophysical Surface Seal Insta <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: Q 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 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 CALLUR A GRPJT/;NVFAPO,rION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED -- -�/w �� ��= TITLE: A DATE: <br /> (DRAW PLOT PLAN ON REVER ESI <br /> FOR DEPARTMENT USE ON7 <br /> PHASE I <br /> 77 <br /> APPLICATION ACCEPTED BY ,.,., DATE ,^• <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> EH 14 26 Rev. 9/78 N69/7 2M <br />