Laserfiche WebLink
� SAN JOAQUIN LOCAL HEALTH DISTRICT ---.. <br /> LZA <br /> "FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No, '7.A --lc <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued /� <br /> i <br /> (Eomp'lete In'-Triplicate). <br /> Application is hereby made to the San- Joaquin Local Health District for a <br /> Pp y q 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 Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS CITY%TOW N <br /> Owner's Name _. gvrc Phone_ f� %1 <br /> ,Address City, _ <br /> Contractor's Name License Phone �y <br /> IS CERTIFICATE OF WORKMAN'S CO"MPENSATION INS14AMrF ON FILE WITH SJLHD? NO <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN 0 RECONDITION C].. DESTRUCTION[- <br /> WELL CHLORINATION E] ELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION U PUMP REPAIR p PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK_Z6j2t SEWER LINES/OC}�.- PIT PRIVY -� <br /> SEWAGE DISP SO & FIELDZQLL CESSP OL/S PAGE PIT " _— OTHER NI <br /> PROPERTY LINid FPRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> _ I <br /> INTENDED USE TYPE.- OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation r� <br /> Domestic/private Drilled Dia. of Well Casing ._ <br /> Domestic/public Driven Gauge of Casing , <br /> IrrigationGravel Pack' Depth of Grout Sea <br /> Cathodic Protection _Rotary Type of Grout Ac <br /> Disposal Other--` Other Information ------ <br /> Geophysical Surface Seal <br /> PUMP INSTALLATION: Contractor CJ - <br /> Type of Pump H.P. / <br /> PUMP REPLACEMENT: [State Work Done '? ' <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION 'OF WELL: Well Diameter Approximate Depth <br /> Describe Materia an Proce ure <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 R0U. IN ION. PRIOR TO GROUTING AND A`FINAL INSPECTION. r <br /> SIGNED `r � <br /> TITLE: DATE: <br /> DR L N ON REVERSESIDE <br /> FOR DEPARTMEN ' USE• ONLY <br /> PHASE I. <br /> APPLICATION ACCEPTED BY ,:� RATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION I ls-0 /6D PHASE IIL FINAL PdSPECTION <br /> I:NSPECTIQN BY DATE /_2/2// 20c, INSPECTIDN BY �` DA (� i. <br /> Eli 14 26 RPV_ 9/7R ,f r � -7o 4 �� <br />