Laserfiche WebLink
SANcJOAQUIN LOCAL -HEALTH DISTRICT <br /> FFICE USE -1601 E. Hazelton Ave. , Stockton, CA 95205 Pgrmit No. <br /> Telephone: `'(2Q9) 466-6781 `$ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued - '7g <br /> ` This Permit. Expires 1 Year From Date Issued <br /> L— 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 t,C CITY/TOWN <br /> Owner's Name Phone <br /> Address City . <br /> Contractor's Name License . Phone_Z-2. <br /> IS CERTIFICATE OF -WQRKt1Ar4'S COriP SATIO`f INSURANCE ON FILE WITH SJLHD?AYES NO <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION [2 DESTRUCTION C]WELL CHL RINATION ❑ WELL ABANDONMENT ❑ OTHER❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT EJ W <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> = <br /> PROPERTY LINE -, PRIVATE DOMESTIC TELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFI.CA. TWNS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing. <br /> 6- <br /> Domestic/public Driven Gauge of Casing J <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed b <br /> PUMP INSTALLATION: Contractor <br /> Type. of.. Pump H.P. <br /> PUMP REPLACEMENT: .� Q 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 s to Workman's Compensation <br /> laws of C l ifornia. " - ---� - -- -; <br /> I WILL CAL F R A GROUT INJICTION PRIOR TO GROUTING 4NDA INA ECT / <br /> SIGNED ' TITLE: DATE: CO <br /> (DRAW PL T PL N ON REV E SIDE <br /> FOR DEP RTMENT 8t ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ��i <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION �+ <br /> INSPECTION BY DATE INSPECTION BY,4 DATE . _rte <br /> EH 1426 Rev. 12-7 � _ ___ _ 1/78 2M I <br />