Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> _FOR- OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 2,Y -2,5 F <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> (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. p j <br /> EXACT STREET ADDRESS Is ���r CITY/TOWN Gs <br /> Owner' s NamePhone <br /> Address S City „ �s.•=� <br /> Contractor' s Name Li cense# C9 A 71.-4'"Phone �►. —7�� <br /> TS CERTIFICATE OF WORK"IAN'S CO"ANSATION INSURANCE ON FILE WITH SJLHD? YES '1G NO <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN ❑ RECONDITION ❑ DESTRUCTION[] � <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION CI PUMP REPAIR❑ PUMP REPLACEMENTj� <br /> dQ <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 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type .of Pump H.P. �f <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP I4=44: '( State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordant <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 GROUT INSPEC N JROR-10 GROUTING AND A FINAL INSPECTION. <br /> SIGNED ITLE: DATE: <br /> 71 le� f <br /> PL ON REVERS SI E <br /> PHASE _ <br /> FOR DEPARTMENT SE ONLY <br /> I e�z � <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE II-I FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY E - - DATE 7-17 <br /> LH 1.4 26 Rev. 9/78 G-:�)5/79 2M <br />