Laserfiche WebLink
SAN JOAQUIN L'7LAL HEALTH UIS f Mc l <br /> FFICE USE: 1601 E. Hazelton Ave. ; Stockton, CA 95205 Permit No. -I�K 16 a,7 <br /> W Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date, Issued 7740fri <br /> / This Permit Expires I Year From Date Issued <br /> (--o 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 ADDRESS1A) CITY/TOW, <br /> f� k <br /> Owner's Name Phone <br /> - 1 <br /> Address City <br /> Contractor,'s -Name r- �* � ,, icense# Phone <br /> � � Z L� 3 <br /> IS CERTT'FICATE OF WOR.11AId'S C0t"IPFN T "1 INSURANCE FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL16 DEEPEN ❑ RECONDITION ❑ DESTRUCTION Ej <br /> WELL CHLORINATION 0 WELL ABANDONMENT p OTHER n <br /> PUMP INSTALLATION 0 PUMP_REPAIR❑ PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY 1 <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER ' <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICA NS <br /> Industrial t Cable Tool Dia. of Well Excavation <br /> Domestic/private - Drilled Dia. of Well Casing Virl <br /> Domestic/public Driven - " Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal °, <br /> Cathodic Protection Rotary Type of Grout t r <br /> J. <br /> Disposal Other 'r y Other Information <br /> Geophysical Surface Seal Installed byX <br /> PUMP INSTALLATION: Contractor r p <br /> Type of Pump <br /> PUMP REPLACEMENT: Q State Work Done <br /> PUMP REPAIR: -"" <br /> QState Work Done �--- <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material an2 Procedure <br /> I <br /> I hereby certify that I have prepared this application and that the work will be done in accordancei <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations o`f the San Joaquin Local <br /> Health District. Home owner or licensed agent's signature certifies the foll,owi g: <br /> I certify that in the performance of the work for which this permit is issue I shall <br /> not employ any person- in such manner as to become jec to W man's Corm ation k <br /> laws of California. " `�°� <br /> I WILL CALL F R GROUT INSPECTIO RIOR`TO-GROUTING ND A F to <br /> INS C <br /> SIGNED DATE: <br /> RW. PLOT L ,N ON RE E SIDE <br /> PHASE I <br /> FOR DEPARTMENT SE ONLY <br /> '� <br /> APPLICATION ACCEPTED BY . ,- DATE <br /> A�y <br /> ADDITIONAL COMMENTS : - <br /> PHASE II GROUT INSPECTION PHASL II -fINAL INSPECTION <br /> INSPECTION BY. DATE = ti��� { INSPECTION BY DATE 1V` <br />