Laserfiche WebLink
h <br /> SAN JOQElIN LOCAL HEALTH DISTRICT <br /> E USE: 1601 E Hazelton Ave. ,: Stockton, CA ` 95205 Permit No.w,jg,5,� <br /> Telephone: (2I39) 466.6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued y_2 7 <br /> (� (Eomp 1 ete ,I n Tri p1 i Cate <br /> l <br /> Application is hereby made to the San Joaquin Local Health, 01strictt•for a permit"'' o construct, . <br /> and/or install the work herein described. This application- is made'in complianceIwith" San ' <br /> County y o <br /> Joaquin Ordinance No. 1862 and the .Rules and,R .ulatons of the San Joaquin Loda Health <br /> District. <br /> EXACT STREET ADDRESS Q CITY/TkIWNii+ <br /> Owner's° Name , Phone .. , <br /> Address city <br /> Contractor's Name icense# hone <br /> S C RTIFI AT -OF WORIC%N'S AIO <br /> NjNSURANgE 9=1IL WITH SJLV YES <br /> 1—y—PEMOF WORK (Check): NEW WELL DEEPEN RECONDITIONS DESTRUCTIANC3 <br /> WELL CHLORINATION Q WELL ABANDONMENT Q OTHERS Q, <br /> PUMP INSTALLATION Q PUMP REPAIR 0 PUMP REPLACEMENT'Q —� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPUSSAC7IELD C /SEEPAGE OTHER <br /> PROPERTY LINE PRIVATFWESTIC WELL,===PURL ESTIC C� <br /> t INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIQNS <br /> Industrial — Cable 'TFo1 Dia. of ,fill 'Excavatlon <br /> _Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> , _Irrigation Gravel Pack7 Depth �of Grout ea <br /> Cathodic Protection_ Rotary Type.Qf Grout <br /> Disposal `­Other�, Other ,Infor"at on <br /> Geophysical Surface* Seal Insta T67 <br /> PUMP INSTALLATi.ON: Contractor <br /> Type of Pump _ <br /> PUMP REPLACEiytNT: C3State Work Done <br /> PUMP ' . <br /> ,um aw. tR: :, SIState Work Done <br /> ESTRUCTION O�F WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 1 hereby ,certify that I have prepared this application and that the work will be done in actwordo <br /> With San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San `Joaquin I I", <br /> Health District,. Home owner or Ticensed 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 ft�nner as to become subject to ;klorkman'sCompensation <br /> laws of California. <br /> WILL CALL FOR A GROUT INS ' PRI . 0 -GROUTINGAND A'FINAL IN R€CTION* <br /> SIGNED <br /> T LE DATE : ,. <br /> MT PL_Pff% REVS 51DEj, <br /> M EY <br /> PHASE I .-... <br /> SLI iON ACCEPTED BY <br /> GATE <br /> ADDITIONAL,COMMENTS: <br /> t <br /> PHASE I N ECTION <br /> RfIASE III f 1NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY �. DATA '1,7 <br /> / .,g <br /> EH 1426Rev. 978 <br />