Laserfiche WebLink
SAN JOAQUIN LOCAL., LTH DISTRICT <br /> F�—�—FFTCLUSE: y 1601 E. Hazelton Ave. , Stockton, CA 95205 Perm it 16 -W <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued (,)-71 <br /> This Permit Expires 1 Year From Date Issued <br /> 1' 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 ADDRESSJ <br /> CITY/TOWN <br /> Owner's Name (.C? Phone <br /> Address OP City <br /> Contractor' s Name License �/ Phone_ ,-2-2 1631 <br /> IS CERTIFICATE OF WRKMAN'S COMP SATION INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 0 OTHER ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT ❑ tN <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 SPECIFICAT O <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 Sea <br /> Cathodic Protection —ZFw.7--Ro ta ry Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed' a: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H. <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe MateriaT--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 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 s Workman's Compensation <br /> laws of C ifornia. " <br /> I WILL CAL FPR A GROUT INSPEC PRIOR TO GROUTING AND A FIN INSPEC <br /> SIGNED TITLE: E: <br /> DR W PLOT -PLAN ON REV SIDE y <br /> PHASE I FOR DEPARTMENT ONLY <br /> APPLICATION ACCEPTED BY ,0 DATE7J-70 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION �/++// PHASE III F NAL INSPECTION <br /> INSPECTION BY DATE :2 ljyl INSPECTION BY DATE . -� � <br /> EH_ 1426 Rev. 12-77 1 /78 6A <br />