Laserfiche WebLink
1 <br /> SAN JOAOUIN MCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6781 <br /> �-i� -�� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued a <br /> This Permit Expires I 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 incompliance with San <br /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> 1istrict. <br /> EXACT STREET ADDRESS 1 _ CITY/TOWN <br /> Owner's Name Phone .? <br /> �,r---.–.— - <br /> IC <br /> Address , S / - City' <br /> Contractor's Named6 _ Li cense Phone/ / ' <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIOt! INA?ICE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL[f DEEPEN ❑ RECONDITION Q DESTRUCTION d <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION 0 PUMP REPAIR❑ PUMP REPLACEMENT El <br /> DISTANCE TO NEAREST: SEPTIC TAN SEWER LINESyp`�_ PIT PRIVY -- it <br /> SEWAGE DISP�IEL CESSPOOL/SEEPPGE PIT OTHER <br /> _ PROPERTY LINFiVORIV_�_ if <br /> WELL 10-11_ PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �I <br /> Industrial Cable Tool Dia. of Well Excavation � rr <br /> Domestic/private Drilled Dia. of Well Casing rr �� <br /> Domestic/public : Driven Gauge of Casing iF <br /> Irrigation Gravel Pack Depth of Grout Seal", <br /> Cathodic Protection Rotary Type of Grout��4,04 <br /> glgt <br /> Disposal —Other Other Information <br /> Geophysical Surface Seal InstaTTe <br /> I <br /> PUMP INSTALLATION: Contractor j <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: M State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION.-OF WELL.:i 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 Localf <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 IVPEf0TION,1PX70R TO GROUTING AND A FINAL INSPECTION. I <br /> SIGNED TITLE: +IEZ DATE: ' <br /> �LRAW PLOT PLAN ON REVERSEVOSIDET ; <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ff ; <br /> ADDITIONAL COMMENTS: 1 <br /> PHASE TA GROUT INSPECTION PHASE III kINAL ASPECTION ' <br /> INSPECTION BY DATE $ INSPECTION B DATE��,;;e <br />