Laserfiche WebLink
SAN JOAQUIN LOCAL -HEALTH DISTRICT <br /> FOR FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.± - Q(�,z <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT' Date Issued 7-lt -%8 <br /> 2 This Permit Expires 1 Year From Date Issued <br /> J (Complete-In T-=i pl i cate <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 CITY/TOWN <br /> 77--ti, <br /> Owner' s Name2 Phone <br /> Address City <br /> Contractor's Name ; License#2 dg/3 Phone5-22 z <br /> IS CERTIFICATE OF WORKt1Aid'S C0 ENSATIO"t"I�JSURAFlCE ON FILE WITH SJLHD? YES - NO <br /> TYPE OF WORK (Check) : NEW WELLA DEEPEN ❑ RECONDITION Q DESTRUCTION❑ � I <br /> rWELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER❑ 4 <br /> P..VMP I-NSTALLATION E7 . PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK ,;4� SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD lid / CESSPOOL/SEEPAGE PIT OTHER <br /> = PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFIC4TJWS. { <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled __ .�. Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal f <br /> Cathodic Protection __Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical ti Surface Seal Installed b <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT. ❑State Work Done i <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: 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 Local ' <br /> Health District. Home owner or Ticensed 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 b come su to Workman's Compensation a, <br /> laws of Cali orni-a." � -� W -� �� - <br /> I WILL CALL EOR/A GROUT INSPECT PRIOR TO GROUTING A FIN I P TION. <br /> SIGNED <br /> TITLE- DATE: <br /> -DR W PL T-TTN RON SIDE) . <br /> FOR DEPARTMENT USE ONLY- <br /> PHASE I x <br /> APPLICATION ACCEPTED BY :;1 DATE <br /> ADDITIONAL COMMENTS:.x ' <br /> _PHASE .II.,_GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION 'BY � DATE_-_47 <br /> cu IAne 170 71A <br />