Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F. FFICE'USE. V 1601 E. Hazelton Ave. , Stockton, CA 95205 EDateIssued <br /> . <br /> Telephone: (209) 4 66781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> t <br /> (i:omplete 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 No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. . A <br /> EXACT STREET ADDRESS-1-0 / 22 _ ° CITY/TOWNf <br /> Owner's Name Phone 3 C, j- 7 <br /> Address Z 0 _ City <br /> Contractor's Name License# 23 Phone Q <br /> IS CERTIFICATE OF, WORKMAN'S COMIPENSATION -INSURAINCE ON FILE WITH SJLHD? YES L=- <br /> TYPE OF WORK (Check) : NEW WELL Q DEEPEN ❑ RECONDITION 0 DESTRUCTION EO I <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER 0 <br /> v PUMP INSTALLATION L PUMP REPAIR❑ PUMP REPLACEMENT Com' <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ... .. PIT PRIVY <br /> SEWAGE DISPOSAL 7IELD CESSPDUI./SEEPAGE PIT OTHER q <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED-USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS -, <br /> r " Ihd t tril Cable Tool Dia. of Wel Excavation <br /> Domestic/private Drilled _ Dia. .of-Well Casing <br /> 'Domest�i.c/pub.l i_d__-—..-..DDri ven Gauge of Casing <br /> Irrigation F Gravel Pack Depth of Grout Sea j <br /> Cathodic. Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed <br /> PUMP INSTALLATION: Contractor <br /> Type of-Pump H.P. <br /> PUMP REPLACEMENT: State Work Done . <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: I <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 CALLR . GROUT INSPECTION PRIOR TO GROUTING- AND A FINAL INSPECTION. <br /> SIGNED <br /> TITLE: DATE• <br /> D P ON REVERSE DE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE -.I <br /> APPLICATION ACCEPTED BY `'� DATE /1---:2 � �5 <br /> ADDITIONAL -COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BYDATE / <br /> EH 14 26 Rev. 9/7RA 4I7R -9M <br />