Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT Pe'r�nit Na, =26- <br /> I <br /> Fog FFICEUSE: 1601 E. Hazelton Ave.-, Stockton, CA 95205 Telephone:. t2Q9) '466-6781 Date Issued <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit Ex fres 1 Year From Date Issued T <br /> Complete In Iriplitate , <br /> r b made to the San Joaquin Local Health District for a pliancetwithnSanct' <br /> Application is he e y lication is made in comp <br /> and/or i�nstal,l the work herein described.. This app ' <br /> ,'aaqu i n Co•Unty erd i nance rYo 1862. and the Rules and ,.Regul ati ons of the San Joaquin Local Health <br /> Cistr�ct• i CITY/TOW, N <br /> EXACT STREET ADDRESS ) Phone <br /> Owner' s Name City <br /> Address License# Phone <br /> Contractor' s Naive <br /> . <br /> _ ' COMPENSATIO"! i'1SURAINCE ON FILE WITH SJLHD? YES I'10- <br /> IS CERTIFICATE OF WORKMAN'S -----_ <br /> TYPE OF WORK {Check)': -NEW WELL CI DEEPEN Q RECONDITION ® DESTRUCTION d O ; <br /> WELL ABANDONMENT <br /> WELL• CHLORINATION [] C] OTHERf� <br /> I PUMP INSTALLATION. q PUMP REPAIR❑ PUMP REPLACEMENTI� ` <br /> i <br /> PIT PRIVY <br /> DISTANCE TO NEAREST". SEPTIC TANK SAL FIELDER LINECESSPOOL/SEEPAGE PIT , OTHER <br /> SEWAGE DISPQ <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 p <br /> Domestic/public Driven` Gauge of Casing <br /> Irrigation gavel Pack Depth of Grout Seal Cathodic Protection L Rotary Type of Grout <br /> Disposal Other— Other Information <br /> Geophysical Surface Seal Installed b <br /> PUMP INSTALLATION: Contractor H, <br /> Type of Pump - r <br /> { St#ate Work Done <br /> PUMP•�REPLAGEMENT: � _ r3 � <br /> A <br /> � -PUMP .REPAIR: QState Work Done <br /> . _�.. - Approximate Depth <br /> DESTRUCTION._QF WELL: .. Wel.11D_iameter cedure71p- <br /> Describe Mate 7a a Pro <br /> 94 <br /> d this application and that the work will do in'�accordan <br /> - I hereby certify that I;have prepare Pp <br /> ' with San Joaquin County Ordinances, State .Laws, and Rules and Regulations of the San Joaquin oca <br /> Health District. Home owner or iiceeseof thenwbrksignature <br /> whichcertifies <br /> permiteisoissued, I- shall <br /> k "I certify that in the performanc <br /> ( not employ any person in such manner as to become subject to Workman's Compensation <br /> laws',of California." ' <br /> � I WILL CALL OR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. { <br /> t TITLE: DATE: .� <br /> SIGNED <br /> # DRW PLOT L N ON REVERSE SIDE <br /> k } FOR DEPARTMENT USE ONLY / �{ <br /> PHASE I i t DATE—d::�f <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: :i PHASE I FINAL INSPECTION <br /> 4, PHASE II GROUT INWCTION DATE <br /> ± INSPECTI.O BY ` DATE INSPECTION BY <br /> 1 /78 21 <br />