Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95206 FDate <br /> t No. <br /> Telephone: (209) 466-6781 _7 �~ � � <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Issued �_ <br /> Th`is., Permit Expires i Year From Date Issued <br /> Complete. In Triplicate ; <br /> Application is hereby made to the San Joaquin Local Health Distri <br /> and/or i ct .for a permit to construct <br /> install the work he re7n described. This application is made in compliance with San <br /> Loan-Jin County Ordinance- No. -062 and the .Rules and .Regulatio s f the San Joaquin Local Health <br /> District. :. 173S,2 -5= gc� � � <br /> EXACT STREET ADDRES e <br /> CITY/TOWN <br /> Owner's Name 4 <br /> ` <br /> Address � Phone <br /> City ,.✓ <br /> Contractor's Name Licensees Phone <br /> . o <br /> IS CFRTIFICATE nr WORKriAN'S COMPENSATION INSURAINCE=0N FILE-,WITH_ SJLH.D?- . YES _x -NO, <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION Cl -.--, DESTRUCTION[j <br /> � WELL,.CHLORINATION <br /> ��PUMP�-INSTALLATION 0 WELL ABANDONMENT Q, i�OTHER 0 <br /> s ❑ PUMP REPAIR❑ PUMP REPLACEMENT -w <br /> DISTANCE TO NEAREST.: SEPTIC TANK SEWER LINES PIT PRIVY f <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC <br /> WELL <br /> INTENDED USE ;,TYPE OF. WELL <br /> Industrial CONSTRUCTIONSPEGIFICATION5 <br /> _' Ca,bl-eFToa11 Dia. of Well Excavation s <br /> Domestic/private Drilled I Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing "I! <br /> Irrigation t Gravel Pack Depth of Grout Seal <br /> Cathodic Protection i Rotary Type of Grout € <br /> Disposal 0ther Other Information <br /> Geophysical Surface Seal Installed by: <br /> i <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PIMP RE.RLACEMENT: State Work Done_ _ . — <br /> J. <br /> _.._....._._M... _.�.___. .. _ ...+ <br /> PUMP REPAIR: ❑State Work Done <br />)ESTRUCTION OF WELL: Well'Diameter , <br /> Describ6 Ma-U6and Proce ure Approximate Depth <br />[ hereby certify that I have prepared this- application and that the work will be done_ in accordance <br /> Jfth San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local <br /> dealth 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 /> WILL CALL FOR A GRO IN PECTION PRIOR TO GROUTING ANCTION. <br /> IGNED � TITLE: <br /> DATE: <br /> U A F I NA INSPE <br /> I DR W PLOT PL N ON REV RE SIDE <br /> HASE I FOR DEPARTMENT USE ONLY <br /> PPLICATION ACCEPTED BY DATE <br /> DDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> VSPECTION BY DATE �` INSPECTION BYGii DATE <br />. 1426 Rev. 12-77' <br />