Laserfiche WebLink
SAN JUAQUIN LUGAL HEALIH UISIKILI <br /> BICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. - <br /> Telephohe: (209) 466 .6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 7/3I <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 Joaquin Local Health <br /> °District. <br /> ,EXACT STREET ADDRESS 6 % ", ® J/¢ CITY/TOWN <br /> Owner's Name Phone " <br />'Address G City <br /> Contractor' s Name Li cense#7 ,,/Gv y Phone G-_ ;� r 7 <br /> IS CERTIFICATE OF WORKMAN'St,1PENSA�IC�IINSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL I DEEPEN O RECONDITION DESTRUCTION(] <br /> WELL CHLORINATION D WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION 0 PUMP REPAIR❑ PUMP REPLACEMENT <br /> DISTANCE TO NEARLST:- -"SEPTIC TANK z SEWER LINES PIT PRIVY <br /> + SEWAGE. DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -, PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED__USE A- <br /> - TYPE -OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial �Cable Tool Dia. of Well Excavation 2, <br /> Domestic/private Drilled Dia. of Well Casing t <br /> Domestic/public Driven Gauge of Casing k <br /> X Irrigation 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 />'5PUMP INSTALLATION: Contractor r <br /> Type of Pump H.P. 5 <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate- Depth <br /> Describe Material and Pr.oce ure <br /> A <br /> I hereby certify that I have prepared ..thi.s application and that the work will be 'done in accordance. <br /> With San Joaquin County Ordinances; .-State -Laws , and Rules and Regulations of thef,San Joaquin Local ; <br /> Health ,District. Home owner or licensed agent's signature certffi-e-s-the-following: <br /> "I4 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 /> � <br /> I: WILL CALL "FOR A GROUT--29MTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED �� - TITLE: DATE: d, <br /> k <br /> DR W PLT L N ON REVER E SIDE <br /> PHASE I FOR DEP RTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ; <br /> PiTE174 <br /> AQDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE IIA FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION 8 DATE <br /> 2-'7_I _ _ - w 1 i /.7 R- 2M - <br />