Laserfiche WebLink
moo#3 <br /> SAN JOAQUIN LOCALIHEALTH DISTRICT #1 <br />-�-EO.R OFFICE USE: 1601 E. Hazelton Ave. ;' Stockton, CA 95205 Permit No.72//1-7. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT " Date Issued a <br /> This Permit Expires 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 r <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 fl,-- CITY/TOWN d <br /> Owner's Name s Phone . <br /> Address �� W � Cit y ftdC- <br /> Contractor's <br /> Name : �, License# Phone ( ' <br /> IS CERTIFICATE OF WORKMAN'S COMIPENSATIO'N INSURANCE ON FILE WITH SJLHD? YES I40 <br /> TYPE OF WORK (Check) : NEW WELL C] DEEPEN ❑ RECONDITION [D DESTRUCTIONE3 � <br /> WELL CHLORINATION 0 WELL ABANDONMENT OTHER <br /> PUMP INSTALLATION 'S PUMP REPAIR L PUMP REPLACEMENT .Q <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private _Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing G <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information , <br /> Geophysical Surface Seal Instal ed b <br /> PUMP INSTALLATION: Contractor AaA A 1% <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: 71State Work Done <br /> , <br /> PUMP REPAIR: ❑State Work Done i <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Proce ure <br /> . 1 <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 G UT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED r �� TITLE: DATE: <br /> DR W PLT PLTN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY . <br /> ADDITIONAL COMMENTS: <br /> J PHASE II GROUT INSPECTION PHASE III UVAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY" DAT� <br /> - - - - - - -- <br /> /W . 9M. <br />