Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT _ ; <br /> !j_QFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 7 <br /> 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 permit to construct <br /> and/or install the work herein described. This application is made in compliance with San <br /> ,'oanui n County Ordinance No. 18 and th R es and. Regulations of the San Joaquin Local He lth <br /> District. 3jt�� ���� <br /> EXACT STREET ADDRES -AL �� �n��`� CITY/T0WNI /v-?—7— <br /> Owner's Name,Z?1 VES- E-z0 Phone X4 X57/,/ <br /> Address 9at9" -v� City <br /> Contractor's Name 1 Tw PTJ A4 License#f6 Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATI01 INSURANCE ON FILE WITH SJLHD? YES to NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER 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 /> 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 H.P. <br /> PUMP REPLACEMENT: []State Work Don <br /> PUMP REPAIR: (State Work Do <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 CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED 4 ,^ y., TITLE: g, DATE: <br /> (DRAW PLOT PLAIN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �� / <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS : <br /> PHASE II G VUT INSPECTION PHASE N I FINAL INSPECTION <br /> INSPECTION BY A DATE INSPECTION BY ,U DATE <br /> EH 1426 Rev. 12-7"7 P...% ,���ol 1/78 _ 2M <br />