Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.7=4 U g <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT I Date Issued s ,5_9 7 <br /> (Complete 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. , <br /> EXACT STREET AD ESS % Qi / CITY/TOWN_�20l <br /> Owner's Na a ,�! Phan -7- 21 <br /> Address ti City <br /> Contractor's Nam - % U Licer'se� Q Phone 7J —� <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURA"NCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL-0 DEEPEN Q RECONDITION Q DESTRUCTION[� w <br /> WELL CHLORINATION 0 WELL ABANDONMENT p OTHER 0 � <br /> PUMP INSTALLATION M---'SUMP REPAIR 0 _. PilMP REPLACEMENT Q <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY L <br /> SEWAGE DISPOSAL IELD CESSPOOL/SEEPAGE P�� OTHER <br /> PROPERTY 'LINE - PRIVATE DOMESTIC WELL PUBLIC D MESTIC WEL <br /> INTENDED USE TYPE OF WELL, CONSTRUCTION, SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> ��aomestic/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 /> - - Disposal her Other Information <br /> Geophysical Surface Seal nsta ed <br /> PUMP INSTALLATION: Contractor <br /> Type of 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: <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 lifornia. " <br /> I WILL CALL 0 A GROU INSPECTIO P IOR O� GROUTING ANDz4INAL -INSPECTION. <br /> SIGNED TITLE: DATE:AZe A <br /> R W L N ON RE SIDE <br /> PHASE I R P 'TMENT USE ONLY <br /> PPLI ATION ACCEPTED BY r', C DATE <br /> ADDITIONAL COMMENTS: <br /> 11 I <br /> PHASE II GROUT INSPECTION W-- <br /> INSPECTION BY PHASE III FINAL INSP CTION <br /> DATE INSPECTION BY � DATE <br /> EH 14 26 Rev. 9/78"- <br /> /78 9/78 2M-_ <br />