Laserfiche WebLink
! SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.Zf-,;z a- <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. Locai Health <br /> District, <br /> EXACT STREET AbDRES_ zf s C"ITY/TOWN1Z <br /> Owner's Name - Phone 6-1— Svc 6- <br /> Address <br /> Contractor's Name .,i- License# Phone <br /> I5 CERTIFICATE OF WORKMAN'S COIMPENSATIOM INSURANCE ON FILE WITH SJLHD? YES <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION DESTRUCTION <br /> ORI <br /> WELL CHLNATION 0 WELL ABANDONMENT OTHER 0 <br /> PUMP INSTALLATION PUMP REPAIR❑ " PUMP REPLACEMENT Q .. O.{ <br /> f <br /> DISTANCE TO NEAREST: : SEPTIC TANK /1D 'SEWER LINES�pPIT 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 /> IndustrialCable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well. Casing.- <br /> Domestic/publi"c Oni_ven . .,,,.,�` ,�." Gauge. of Casing >� <br /> Irrigation a, Gravel Pack -'Depth of°Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information c i <br /> Geophysical Surface Sealnalled b <br /> PUMP INSTALLATION: Contractor i <br /> Type of Pump H. <br /> PUMP REPLACEMENT: Q State Work Done ,,,,. <br /> PULP REPAIR: ❑State Work Done -.. <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth " <br /> Describe Material ana Procedure <br /> I� hereby certify that I have prepared this application and that the work will be done in accordance ' <br /> Frith 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 i <br /> not employ any person; in such manner as to become subject to Workman's Compensation <br /> law of California. <br /> I WILL A R GROUT INprrTMM PRIOR TO GROUTING AND A FINAL INSPECTION. , <br />;IGNED TITLE: �,� DATE: <br /> D P N ON REVER E SIDE) <br /> I <br /> CHASE I OR DEPARTMENT USE ONLY <br /> UP—PLICATION ACCEPTED BY —l DATE z ZZ/Z <br /> kDDITIONAL COMMENTS: I <br /> PHASE II GROUT INSPECTION <br /> PHASE III FINAL INSPECTION <br />'NSPECTION BY DATE ' <br /> INSPECTION BY DAT <br />:H' 14 26 Re,v. 9/78 s. _ . ._ - 9/ 2M <br />