Laserfiche WebLink
flJ , <br /> SAN JOAQ01 N -LGCAL HEALTH DISTRICT <br />�QFFICE USE: 1601 E. Hazelton Ave. ,' Stockton, CA 95205 Permit No. <br /> Telephone: (209) .466-6781 <br /> - t Date Issued <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT i <br /> This Permit Expires 1 Year From Date Issued <br /> L p�;2 Complete In Trip irate <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 Regulatio of the San Joaquin Local health , <br /> District. <br /> EXACT STREET ADDRESSA 2 CITY/TOWN <br /> s <br /> 1 7 <br /> Owner' s Name Phone 1 <br /> Address City <br /> Contractor's Name.. License p Phone ~z�- <br /> IS CFRTIFICATE� OF WORKMAN'S COm NSATIO'! -INSURANCE ON FILE .WITH SJLHD?l YES-- NO <br /> TYPE OF WORK (Check) : NEW WEL EPEN ❑ RECONDITION ❑ DESTRUCTION[) ! <br /> WELL CHLORINATION❑ WELL ABANDONMENT ❑—OTH-ER 0--- <br /> PUMP <br /> --PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT ❑ r <br /> DISTANCE TO NEAREST: SEPTIC TANK _SEWER L-INES .--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 SPECIFI. IWS <br /> Industrial Cable Tool Dia. of 'Well . Excavation <br /> omestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <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 <br /> PUMP. INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: u ❑State Work Done <br />' DESTRUCTION OF WELL: Well Diameter Approximate Depth? ` <br /> ~Describe Material an2 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 licensed agent's signature certifies the following: <br /> -I certify that in the performance of the work foMFI <br /> is permit is issued, I shall <br /> not employ any person in ,such,manner as to becomto Workman's Compensation <br /> laws of Calif rnia. " <br /> I WILL CALL FOR GROUT INSPECT PRIOR TO GROUTINGAL NSP I <br /> SIGNED — TITLE: DATE: <br /> (DRAW PLOT PL N ON REV SIDE ;— <br /> FOR ,DEPARTAENJ__USE ONLY <br /> PHASE I . <br /> APPLICATION ACCEPTED BY - DATE�.�' � <br />' ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS III Q. AL INSPECTION <br /> INSPECTION BY DATE 7 r- YyINSPECTION BY DAT <br /> I <br /> j <br /> CU "A0-- 7-1 -712 2M <br />