Laserfiche WebLink
- SAN JOAQUIN LUCHL HLALIH UII ICI � <br /> FOR FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> - "= a Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL 66 S'TRUCTION OR PUMP PERMIT Date Issued 7-( --7� <br /> This Permit Expires 1 Year From Date Issued <br /> Complete In Triplicate <br /> Application i?h�ereby 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 compli-ance with -San <br /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaqu-u Local Health <br /> District. <br /> EXACT STREET ADDRESS ' . CITY/TOWN �- <br /> Owner's Name c Phone <br /> Address City <br /> Contractor's ,Name_ " _License Phone <br /> IS CERTIFICATE OF W RKttAtd'S COMPENSA IO.M MSUR'ANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN E] ,RECONDITION [DDESTRUCTION❑ <br /> WELL CHLORINATION Q WELL .ABANDONMENT ❑ OTHER 0 <br /> PUMP INSTALLATION El PUMP.'�REPAIR❑ PUMP REPLACEMENT W <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER 7 <br /> PROPERTY .1INE -. PRIVATE DOMESTIC WELL . PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIOV./ <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Naommestic/public <br /> estic/private f Drill-ed - .Dia. of Well Casing <br /> Driven Gauge of Casing"t _ f_ <br /> Irrigation Gravel Pack,,, Depth of Grout Seal s <br /> Cathodic Protection N.Rotary Type of Grout 1 , <br /> Disposal / Other Other Information / <br /> Geophysical Surface: Seal Installed 'b P. <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> 1 <br /> PUMP REPLACEMENT: p State Work Done ' <br /> PUMP REPAIR: [b State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth - <br /> Describe Materia an Procedure =;k, <br /> I hereby certify that I have prepared this application and that the work wi11:, be done in accor ancell` <br /> with San Joaquin County Ordinances, State Laws , and Rules and Regulations of the San Joaquin L „ al <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 became s b ' to Workman's Compensation i <br /> laws of California. " j <br /> I WILL CALL 0 A GROUT INSPECTI -PRIOR-,T�O GROUTIN AND A FI AL IN T ON <br /> SIGNED61TITLE : DATE <br /> //.:99::� Ll-R W PLOT PLAN ON REVS IDE I <br /> FOR DEPARTMENT UTt ONLY <br /> PHASE I f' <br /> APPLICATION ACCEPTED BY� DA11T-FA7 <br /> ADDITIONAL COMMENTS: <br /> PHASE Ii GROUT INSPECTION PHASE -IIL FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY 01A DATE <br /> FH ia79 Rot► 79"7 G W1 '/7R 7M <br />