Laserfiche WebLink
SAN.JOAQU:I.N LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 . E. Hazelton. Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6781 <br /> ' <br /> . <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued _130 <br /> This 4Permit. Ex i.res I. Year From Date Issued <br /> 14. 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 />-oaquin County Ordinance No. 1862 and the- Rules and Regulations of the San Joaquin Local Health I <br /> District— <br /> EXACT <br /> EXACT STREET ADDRESS _:5� 2tc)vf CITY/TOWN <br /> Dwner' s Name Phone �� _ <br /> Address City— yZZOO 1/, <br /> Contractor's Name Lice"s ,S PhoneCi/ <br /> TS CERTIFICATE OF WORKMANd'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES_ X ___N__O - <br /> TYPE OF WORK (Check) : NEW WELL L3'— DEEPEN ❑ RECONDITIONt,❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION a-PUMP REPAIR❑ PUMP REPLACEMENT ❑ �? <br /> DISTANCE TO NEAREST: SEPTIC TANK/f___Q/��,6SEWER LINES _ PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINV <br /> 4ZT,RIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIO_N_S_ <br /> Industrial I Cable Tool Dia. of Well Excavation <br /> `Domestic/private 11 Drilled Dia. of Well .Casing <br /> Domestic/public �� Driven - Gauge of Casing j <br /> Irrigation Gravel Pack Depth of Grout Seal S - <br /> Cathodic Protection V Rotary Type of Grout. 5? SA r� <br /> Disposal Other Other Information <br /> Geophysical �I Surface Seal Installed by: �? <br />'UMP INSTALLATION: Contractor d I` <br /> Typo of Pump,, H.P. +f <br />'UMP REPLACEMENT: V ❑States.Work7Done <br />)UMP REPAIR: v'+ CiState Work'/ <br /> Done ' <br />)ESTRUCTION OF WELL:- Weil Diameter Approximate Depth <br /> Dekribe-Mate'rial and Procedure <br />[ hereby certify that I 'have .prepared this application and- thatTthe work will be done in accordance` <br /> vith San Joaquin County Ord nances; State-Laws,-and-Rules-and Regulations of the San, Joaquin Locall <br /> iealth District. Home owner °or licensed agent's signature�certif --es the following: <br /> "I certify that in theiper�formance 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 />[ WILL CALL FPR A GROUT INSPECTION PRIOR TO-GROUTING AND A FINAL INSPECTION. <br /> SIGNED ] ! TITLE: DATE: <br /> (DRAW PLOT PLAN .ON REVERSE SIDE <br /> =i FOR DEPARTMENT SE ONLY , <br />'HASE I 1'/' k <br /> APPLICATION ACCEPTED BY ,1 DATE_ .3 6� 77 <br /> kDDITIONAL COMMENTS : iI <br />• _ -' -- PHASE - I GROUT INSPECTION "` PHASE IIT FINAL INSPECTION <br />.NSPECTION BY Il DATE 7�l6'?/J INSPECTION BY DATE 1214 <br /> � <br />:H.�1426 Rev. 12-77 1178 2� <br />