Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> P_�JFFICE USE: 1601 E. Hazelton Ave. , Stockton„ CA "°95205 Permit No. <br /> Telephone: (209) 466-6781 -\ <br /> APPLICATION FOR WELL CONSTRUCTION OR "PUMP PERMIT Date Issued Vf3 7y <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permi't .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 R and' Regulations of the San Joaqui cal Health <br /> District. % 1 <br /> EXACT STREET ADD RR S {CJ CITY/ <br /> Owner's Nam C , <br />-Address �l� / Phone <br /> Cit 2' <br /> Contractor's Namecc <br /> �!.'icense 23 hone <br /> IS CERTIFICATE -OF WORKMAN'S COMIPENSATION I SURAINCE ON FILE WITH-SJEHD? YES <br /> TYPE OF WORK-(Check) : NEW WELL 01 ' DEEPEN ❑ -� RECONDITION.0 DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 0 OTHER 0 � <br /> PUMP INSTALLATION ❑ PUMP REPAIR C7" REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ' PIT PRIVY <br /> SEWAGE DISPOSAL FIELD " CESSPOOL/SEEPAGE Pim— OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC D MESTIC WELL <br /> INTENDED USE TYPE OF "WELL., CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool '" Dia. of Well Excavation LP <br /> Domestic/private ' Drilled Dia, of Well Casing , <br /> Domestic/public Driven Gauge,of Casing <br />_Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout <br /> DisposalOther OtherInformation <br />_,_Geophysical Surface Seal Insta ed b <br /> PUMP INSTI L,4TION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: Q-State -Work- Do <br /> PUMP REPAIR: _MSfate'Work' <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materia and Proce ure <br /> I hereby certify that I have prepared this application and that the work will " be done in accordance <br /> Frith San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local' <br /> iealth �District, home owner or licensed agent's signature certifies the following: <br /> It 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 /> C WILL CALL FORA GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br />;IGNED TITLE: ,, �,� „� DATE: 11 <br /> D W PLOT L N ON REVERSE SIDE <br />'HA`SE I. F R DEPARTMENT USE ONLY <br /> PP�LIICATION ACCEPTED BY DATE <br /> IDDITIONAL COMMENTS: <br /> t <br /> PHASE I1- GROUT INSPECTION PHASE III FINAL INSPEGTI <br /> NSPECTION BY-, M DATE INSPECTION BY `l ,�, F <br /> H 14 26 Rev. 9/7$ r s��-- _DATE a <br /> 97779 ; <br />