Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT permit No. ` <br /> 21- 541-a <br /> FQR FFICE USE: 1601 E:. Haz.elton Ave. , Stockton, CA 95205 <br /> Telephone: (209) 466-6781 <br /> Date Issued <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Q <br /> (Complete In Triplicate) ' <br /> Application is hereby made to the San Joaquin Loca:l ' Health District for a permit to construct <br /> and/or install the work herein descrtbed.e This application is made in compliance with San <br /> Joaquin County Ordinance No. 1862 and the Rule's and Regulations of the San Joaquin Local Health <br /> District. / <br /> EXACT STREET ADDRESS S ' .�ev Q/Z� CITY/fiOCPiQ� <br /> Owner's Name /S Phone <br /> Address <br /> City, <br /> Contractor's Name "1&1 Cicens Phone <br /> cIS CERTIFICATE OF WORK?IAN'S COMPENSATION INSURAINCE ON FILE WITH SJLHD? YES �►� 0 <br /> b' <br /> TYPE OF WORK (Check) : NEW WELL Kr' DEEPEN ❑ RECONDITION DESTRUCTIONEJ -� <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER FJ <br /> PUMP INSTALLATION PUMP REPAIR C7 PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK/c�j'_SEWER LINES�� PIT PRIVY <br /> SEWAGE DISPOSAL FIELD _ -�-- CESSP00L/SEEPAGE PIT,e �THER <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 /> 4--'Domestic/private drilled Dia. of Well Casing �z <br /> Domestic/public Driven Gauge of Casing—_ <br /> 4 <br /> L---Irrigation —GravelPack Depth of Grout Sea o <br /> Cathodic Protection —T�`Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical _ -- _ -.Surface. Seal Ins ta ed _. <br /> PUMP INSTALLATION: Contractor �^ S -- <br /> Type of Pump .� H.P.�-- ---- <br /> PUMP REPLACEMENT: []State Work Done F <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approx_amate- 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 /> k not employ any person in such manner as to become subject to Workman-'s Compensation <br /> k laws of California." <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING ANDA FI AL INSPECTION. <br /> TITLE: 15 DATE: <br /> SIGNED (DRAW PLUI PLAN ON REVERSE SI E <br /> OR E RIME USE ONLY <br /> PHASE I <br /> ' APPLICATION ACCEPTED DATE <br /> Fhq <br /> iADDITIONAL COMMENTS: <br /> t PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTIONBY____ C DATE a 1� � 1 INSPECTION BY DATE q <br /> r7LI ,A a,-,fl g/ g 2M_ <br />