Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT.[��! 4 <br /> FFICE USE: ' 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No._1 4-bz-3 <br /> Telephone: (209) 466-6781 <br /> i <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued ly <br /> This Permit Expires 1 Year From Date Issued <br /> Complete In 'Tripl.icate <br />, Application` is hereby-made to the"'San Joaquin Local Health District for a permit to construct <br /> Viand/or install the work herein described. This application' is made in compliance with San - <br /> iJoanuin County Ordinance Nu..�` 1862 and the Rules and Regulations of the San Joaquin Local Health ' <br /> I` Gistr�ct. <br /> EXACT STREET,ADDRESS 7 4 40 Al CITY/TOWN Ae6p� <br /> Owner' s Name Phone <br /> Address / r City <br /> Contractor's Name <br /> Li c'enso 4 S 3 Phone�� <br /> r. <br /> I$ CERTIFICATE OF WORKMAN'S COMPENSATIOPI IlaSURA"ICE ON FILE WITH- SJLHD? YES __N0� <br /> TYPE OF WORK (Check) : NEW WELLL4 DEEPEN ❑ RECONDITION [] DESTRUCTION <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 0 � <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK Q WER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FTELD CESSPOOL/SEEPAGE PIT OTHER <br /> _- PROPERTY LINE/ - RIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS.-- a <br /> Industrial ' Cable Tool Dia. of Well Excavation Domestic/private Drilled Dia. of Well Casing / <br /> Domestic%-public 'Driven Gauge of Casing__ <br /> _Trrigat1on Gravel Pack Depth of Grout Sea <br /> Cathadi c• Proteeti on _Rotary Type, of Grout _ � . <br /> Disposal �- Other `~ Othe'rOnformation . <br /> Geophysical Surface, Sea1.,Installed� <br /> PUMP INSTALLATION: Contractor. ,� <br /> Type of Pump ,�, H.P. <br /> PUMP` REPLACEMENT: []State Work Done '''_ E _. <br /> PUMP ?REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> '�� � Approximate Depth <br /> - Describe Materia an Procedure <br /> I hereby certify that I have prepared this appl'i.cation and that the work will be done in accordance <br /> with San Joaquin County Ordinances , State Laws„ and Rules and Regulation's 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 became subject to Workman's Compensation <br /> laws of California. " <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED' 71 TITLE: DATE: <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FO DE ARTME NT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS : <br /> PHASE II PROUT INSPECTION PHASE III FINAL INS ECTION <br /> INSPECTION BY DATE INSPECTION BY DATE `�•O .�} <br /> X1426 " Rev. 12-77 --- 1 17R 9M <br />