Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE 'USE: 1601 E. Hazeltort_Ave.N Stockton, CA 95205 Permit No.7g-/�Q/ <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Ex ires 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 /> Joaquin County Ordinance No. 1862 and the Rules and Regulations .of the San. Joaqui,n Local Health <br /> District. <br /> EXACT STREET ADDRESS J CITY/TOWN <br /> Owner's Name Phone' <br /> Address- W I rem City e. <br /> Contractor' s Name c. r c_. License#jgZ6Qp Phone ^!3 <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURAINCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL M DEEPEN ❑ RECONDITION [3 DESTRUCTION[] J <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION JO PUMP REPAIR❑ PUMP REPLACEMENT [3 <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 -S—V 44 Y,C. <br /> Irrigation =Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Dispo.sa'l Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMPA NSTALLATION: Contractor .'AEl� ,-- <br /> i <br /> Type of Pump IP H.P. <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <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 FORA ROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNLD TITLE: DATE: �� � <br /> DRAW PLOT PLVN ON REVERSE DE <br /> FOR DEPARTMENT USE ONLY <br />. PHASE I <br /> APPLICATION ACCEPTED BY DATE�7��1� -_ <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 3 <br /> kr ,� 1/78 2M- <br />