Laserfiche WebLink
FFICE USE: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. -a <br /> Telephoner (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERM-IT Date Issued�X.7 <br /> (Eomplete`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 /> Joaquin County Ordinance Nod 1862. and the Rules and- Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS <br /> CITY/TOWN . <br /> Owner's Name Phone , <br /> Address <br /> it L <br /> ,Contractor's Name License hone <br /> I5 CERTIFICATE OF WORHAWS - <br /> COMPENSATION INSURANCE ON FILE WITH-SJLHD? YES 0. <br /> TYPEOFkWORK (Check) : NEW WELL L DEEPEN P( RECONDITION DESTRUCTION[� <br /> WELL OHLORINATION C3 WELL ABANDONMENT p - OTHER 0 <br /> PUMP INSTALLATION PUMP REPAIR[] PUMP- REPLACEMENT Q <br /> ------------- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LIN�S PIT PRIVY <br /> SEWAGE DISPO rFIELD C�/SEEP GE PI <br /> PROPERTY LINE PRIVAT I MESTIC WELL PUBLIC C� DOMESTIC REIS'- <br /> - INTENDED USE TYPE OF.WELL_. CONSTRUCTION. SPECIFICATIONS <br /> In ustrial <br /> Cable Tool Dia. of We Excavation <br /> ,._Domestic/private Drilled Dia, of Well <br /> Domestic/public Driven Gauge of Casing` <br /> Irrigation Gravel Pack ' Depth of Grout Sea <br /> --_ Cathodic Protection Rotar <br /> y ` Type of Grout o <br /> .Disposal �� . @ � � " Other Other Information <br /> .Geophysical Surface Seal Installed <br /> PUMP INSTALLATION: Contractor t 0� <br /> Type of Pump <br /> .P. <br /> PUMP 'REPLACEMENT:; H <br /> ❑State Wark Done <br /> LUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL:' —.Well Diameter <br /> - Describe Material and Procedure Approximate Depth <br /> hereby certify that I have prepared this application and rthat 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 iuch manner_. as to become subject to Workman's Compensation <br /> laws of California." <br /> I WILL C L FOR A UT INSPEC ION PRIOR TO GROUTING AND A FINAL INSDFCTTnN. <br /> SIGNED TITLE <br /> DATE: <br /> ON REVERS IDE <br /> PHASE i <br /> FO DEP RTM NT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE-- <br /> PHASE II GROUT INSPECTION <br /> INSPECTION BY DATE PHASE III 'FINAL INSPECTION f <br />=H 14 26 Rev.—1INSPECTION BY VDATE i �/� <br /> r� <br /> 9/7A Pff <br />