Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.2 <br /> Telephone: (209) 466;.6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Ex ires 1 Year From 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 4nstall 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 Local Health <br /> nistrict. <br /> EXACT STREET ADDRESS ,- L �._ <br /> �: �. � J' CITY/TOWN <br /> Owner's Name <br /> one <br /> Address _ r . r,� City 7" ., <br /> Contractor's Name r� R f� License# r ` h - Phone ` :., ,' "` <br /> IS CERTIFICATE OF WORKtiAN S COMPENSATION IN URANCE ON FILE WITH SJLHD? YES ;10,, <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN CI RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION Q WELL ABANDONMENT ' <br /> Q OTHER 0 s <br /> PUMP INSTALLATION 0 PUMP- REPAIR❑ ' PUMP REPLACEMENT [] <br /> DISTANCE TO NEAREST: SEPTIC°TANKSEWER ,LINES PIT PRIVY <br /> SEWAGE,DISPO AL FIELDS CESSPOOL/SEEPAGE PIT ., . OTHER , <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 /> Domestic/private Drilled pia. of Well Casing rf <br /> Domestic/public Driven Gauge of,Casing <br /> Irrigation W __ ravel Pack Depth of Grout Seal . .... <br /> Cathodic Protection Rotary Type of Grout - <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Instal led b <br /> PUMP INSTALLATION: ,Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: FIState Work Done <br /> PUMP REPAIR: Q 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 /> 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 CAL ; FOR R GROU INSPECTION PRIORrRO GROUTING AND A FINAL INSPECTION. <br /> SIGNED /T` +iTITLE: DATE: <br /> DR W PLOT PLAN ON REVERSE SIDE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> f� <br /> APPLICATION ACCEPTED BY ZA:!!�f <br /> DATE <br /> 4DDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> f <br />.'H 1 d9F Dnii 1 0_77 <br />