Laserfiche WebLink
T SAN JOAQUIN LOCAL:HEALTH DISTRICT <br /> OFFICE USE: 1601 E. Hazelton Ave. ; <br /> Stockton, CA 95205 Permit No. <br /> Telephone: {209} 46b-6781 Date Issued 6 ! <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit Ex ices i .Year From Date Issued <br /> Complete In Triplicate <br /> Application is hereby made to the San Joaquin Local HealthnD15tmade. inrict rcompliancea permit twithnSanuct <br /> PP plication <br /> and/or install the work herein described. This app <br /> th Rules and Regulations of the San Joaquin Local Health <br /> Joaquin County Ordinance No. 1862 and <br /> District. CITY/TOWN 7' <br /> EXACT STREET ADDRESS ' Phone4.kS- <br /> Owner's Name L City <br /> Address r <br /> Phone <br /> Contractor' s Name <br /> CAL <br /> License# <br /> I5 CERTIFICATE OF WORKMAN'S COMPENSATION INSURAIIrr Ofd FILE WITH .SJLHD? YES N0 <br /> TYRE. OF WORK=(Check): ANEW -WELL$4 =' DEE-PEN E]-� RECONDIT-ION0DESTH eT-1- NE3-� _ <br /> WELL CHLORINATION 0 WELL ABANDONMENT <br /> PUMP INSTALLATION Q PUMP REPAIR❑ PUMP REPLACEMENT 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK_LQG_&SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD�ESSPOOL/SEEPAGE PIT OTHER S <br /> PROPERTY LINE -: PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE TYPE OF WELL <br /> s Industrial Cable Tool Dia. of Welt Excavation <br /> ZI <br /> Domestic/private Drilled Dia. of Well Casing <br /> . Domestic/public Driven Gauge of Casing,^SVG _! <br /> Irrigation Vic --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 H.P. <br /> k Type of Pump <br /> PUMP REPLACEMENT: ElState Work Done <br /> r PUMP REPAIR: ❑State Work Done <br /> DESTRUCT-ION -0F�W1=LL: Wel1-Diameter— - <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this ap.p3A.cation and that the work will be done in accordar <br /> with San Joaquin County Ordinances , State=%Laws, and Rules and Regulations of the San Joaquin Loce <br /> Health District. . Home owner or .licensed agent' s signature certifies the following: <br /> "I certify that in the Oerfo=rmance 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 F R A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> TITLE: DATE: <br /> SIGNED: <br /> DR W PLOT PLIM ON REVERSE SIDE <br /> F R D P RTM N USE ONLY <br /> PHASE I DATE 07? <br /> APPLICATION ACCEPTED BY --� <br /> ADDITIONAL COMMENTS: PHASE iI FINAL INSPECTION . <br /> PHASE II GROUT INSPECTION a <br /> INSPECTION BY DATE INSPECTION B C ATE ID z- <br /> .^e <br />