Laserfiche WebLink
;�`SJ-SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> - <br /> FFICE USE: 1601 E. Hazelton Ave.,, Stockton, CA 95205 Permit No. 7g 6 <br />-- <br /> Telephone: ' 9) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 40-7 <br /> 1 <br /> This Permit Expires 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 � I <br /> and/or install the work herein described. This application is 'made in compliance with San <br />.'oam.,;n County erdinance. ,h,o. 1862 and the Rules and Regulations of the San. Joaquin Local Health 11Y , <br /> t <br /> District. <br /> EXACT: STREET ADDRESS CITY/TORN <br /> Owner' s Name Phone — .Z <br /> Address City <br /> Contractor's Nam License�&,4&? Phone jD3 <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO"! ItISURAINCE ON FILE WITH SJLHD? YES <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION DESTRUCTION❑ Zt' <br /> r <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION C7 ti PUMP ,REPAIR C❑ PUMP REPLACEMENT [] <br />.DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -, PRIVATE DOMESTIC WELL - PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Ind ustrial Cable Tool Dia. of Well Excavation <br /> omestic'/private Drilled Dia. of Well Casing_f - <br /> Domestic/public Driven . - Gauge of Casing /' 4Z-,F_ <br /> Irrigation Gravel Pack Depth of Grout Sealer .S� <br /> Cathodic Protection _Rtrf-ary Type of Grout o <br /> Disposal Other Other Information <br /> + Geophysic- al, Surface Seal Inst±al�Nb <br /> PUMP- INSTALLATION: Contractor <br /> Type of ,Pump H.P. <br /> PUMP REPLACEMENT: Q State Work Done F` } <br /> PUMP REPAIR: ❑State Work.-Done <br /> DESTRUCTION OF WELL: Well Diameter / Approximate Depth <br /> Describe Material and 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 wol^k: 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 A GROUT INSPECTION,PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: <br /> DRAW PLOT PL N ON REVERSE SIDE <br /> k <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I r <br />'APPLICATION ACCEPTED BY DATE 7-29 <br /> — <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ATE 9 Z)Z 7 <br />�rW 1 d9r, Dau 19-77 .3 - �'�._ _ 1 /78 _211 <br />