Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br />. �__EQR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. r? 7 ? <br /> �- Telephone: (209) 466-6781 l <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued ?-13-1 <br /> (Complete In Triplicate) <br /> Application is hereby made to 'the San Joaquin Local Health District for a permit to construct i <br /> and/or install the work herein described. This application is made in compliance with San <br /> Joaquin County Ordinance No. 1862 and the R les and Regulations of the San Joaquin Local Health <br /> District. — �1 <br /> """" ' CITY/TOWN <br /> EXACT STREET ADDRESS f I ~" <br /> Owner's Name Phone 36 9 <br /> Address <br /> ` City <br /> Contractor' s Name License# Phone ! <br /> IS CERTIFICATE OF WORK`1AIVS INSURA1110E ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION d <br /> WELL CHLORINATION 0 WELL ABANDONMENT [ OTHER❑ � <br /> I PUMP INSTALLATION 04 PUMP REPAIR❑ PUMP REPLACEMENT [I <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSROOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLTC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Ilia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> y Type of Grout <br /> Rotar T <br /> Cathodic Protection <br /> Disposal Other Other Information <br />` Geophysical Surface Seal nsta]led by: J�}_ <br /> PUMP INSTALLATION: Contractor ire <br /> Type 'of Pump H.P. <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP-REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well 'Diameter Approximate Depth <br />` µ Describe Material and Procedure <br /> I, I hereby certify that I havelprepared 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 GROUT IN CTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNE TITLE: DATE: <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> F R DVARTMEV USE ONLY <br /> PHASE I <br />` APPLICATION ACCEPTED BY rl DATE /3 <br /> ADDITIONAL COMMENTS : t <br /> PHASE II GROUT INSPECTIO PHASE III FINAL INSPECTI N <br /> 4 INSPECTION BY DATE INSPECTION BY DAT <� <br /> 4 <br /> LH 14 26 Rev. 9/78 -779 <br />