Laserfiche WebLink
SAN JOAQUINiLOCAL HEALTH DISTRICT <br /> FQS FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued _ -7 <br /> This Permit Expires 1-Year From, Date Issued <br /> Complete InTriplicate <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. II aelv.#-EXACT STREETADDRESS (� �1X �t CITY/TOWN G� <br /> Owner's Name HASEID& Phone a <br /> Address Z City REX14 011 <br /> Contractor's Name L E 1P SVT License# (� Q Z Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION! INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL 2DEEPEN 0 RECONDITION ❑ DESTRUCTION[2 <br /> WELL CHLORINATION .0 ' WELL ABANDONMENT:.❑ . _OTHER 0 <br /> PUMP INSTALLATION 0 PUMP REPAIR 0—PUMP !R£PLACEMENT CI <br /> DISTANCE TO NEAREST: SEPTIC TANK 50' SEWER LINES �() � PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGEJPIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL: ' '` PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> ndustri al Cable Tool LD.i a. of .Wel l L.Excavation d' �- <br /> Domestic/private Drilled Dia. of Well Casing G <br /> Domestic/public DriveD, Gauge of CasingiZ <br /> Irrigation �� el Pack _ Ddpth of GroutiSeal <br /> Cathodic Protection Rotary Type of`Grout I C1< <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Instal ed by: <br /> PUMP INSTALLATION: Contractor <br /> Type° of Pump' •-' H.P. <br /> PUMP REPLACEMENT: ❑ State Work Donee <br /> PUMP REPAIR:, ❑State Work Done . <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> " Descr-i-be-Materi al- and-Proce ure-Z- <br /> I hereby certifythatI haVeyprepared this application and that �theFwork will be done in accordancE <br /> with San Joaquin County Ordinances.,. State taws , and Rules and Regulations of the San Joaquin Local <br /> Health District. Home ow'ne'r-or incensed 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 td WDrkman's Compensation <br /> laws_of..C.al ifornia." _ -------- <br /> P <br /> I WILL CALL FOR A GROUT INSPECTIONRI0 <br /> T .. ... _. <br /> R TO GROUTING AND A FINAL INSPECTION. 0. <br /> I' <br /> SIGNED TITLE-: WPJU, DATE: O <br /> -- _(DRAW PLT PLTN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> r <br /> INSPECTION BY DATE 1� 7 INSPECTION BY DATE `2/70-' <br /> rU 1 A3 De 1077 1/78 <br />