Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br />—FOROFFI 7gw 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6781 <br /> --I APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 6 <br /> This Permit Expires 1 Year From Date Issued ' <br /> Complete In Triplicate71 <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 /> k2oaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Loc Health <br /> District. <br /> EXACT STREET ADDRESS Ia / CITY/TOWN <br /> Owner's Name Phone <br /> Address City �aa. 2) <br /> Contractor's Name Licensee/3 Phone SyZ <br /> IS CERTIFICATE OF WORKMAN'S C r•4PENSATION INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION C] DESTRUCTION❑ <br /> WELL CHL INATION ❑ WELL ABANDONMENT ❑ OTHER 0 � <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK jut SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD_YW CESSPOOL/SEEPAGE PIT OTHERGl1,et� ap <br /> PROPERTY LINE PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL ] <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS re <br /> Industrial Cable Tool Dia. of Well Excavation ,3 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing /60 4y a <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 hy, ff ' <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: 0 State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth �* <br /> Describe Material and Procedure <br /> e--jell c-� 4- /--. r L & f�oa <br /> -b <br /> I hereby certify that I have prepared this application and that the work will �e one 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 CALL FOR A GROUT I.N5PECTION PRIG GROUTING ANDA JINAL INSPECTION. <br /> SIGNED ITLE: DATE: 6 112 IN <br /> (JfAW PLOT PLff ON REVERS SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY YA11DATE S' <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION Y PHASE J II F NAL I SPECTION <br /> INSPEPTION BY DATE61 <br /> 1 ' INSPECTION B f.* ATE <br />� 1 26 Rev. 12-77 1-_.,, 8 2M <br /> x <br />