Laserfiche WebLink
i <br /> I` SAN JOAQUIN LOCAL HEALTH DISTRICT <br />_FOR. OFFICE USE: '' 1601 E. Hazelton- Ave. , Stockton, CA 95205 Permit No, v <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR .WELL CONSTRUCTION OR PUMP PERMIT Date Issued 7� <br /> ��/� <br /> u This Permit Expires 1 Year From Date .Issued <br /> Complete ,I n.Tri pl i cate . <br /> x <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 Sa-n <br /> �oanuin County Ordinance'.No. 1862 and the Rules and .Regulations of the San Joaquin Local Health <br /> D�Str�ct <br /> EXACT STREET ADDRESS_ <br /> CITY/TOWN <br /> Owner' s Name Phone r <br /> Address S u City , rI <br /> Contractor' s Name ` License#33 l Phone � _ <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD. YES NO <br />' TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION DESTRUCTION Cl <br /> WELL CHLORINATION Q WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT [] <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY W <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 /> Industrial �' Cable Tool Dia. of Well Excavation <br /> Domestic/privatell Drilled Dia. of Well Casing <br /> y Domestic/public 0 Driven - Gauge of Casing <br /> Irrigation ai Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical ;' Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor ` <br /> Type of Pump H• <br /> PUMP REPLACEMENT: r7 State Work Done ps <br /> PUMP REPAIR: `'' ❑State Work Done - r <br />( DESTRUCTION OF WELL: Well Diameter Approximate Depth F <br /> � . Describe Materia and Procedure <br /> I hereby certify that I 'Fhave prepared this application and that the work will be dorie'in accordant( <br /> with San Joaquin Qounty ,Ordinances , State Laws , a°nd. Rules and Regulations of the San.-Joaquin Local <br /> Health District. Home owner or licensed agent' s signature certifies the following:,--' f <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 C A GROUTJ`INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED Z TITLE: DATE: <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT U EONLY <br /> PHASE I /� <br /> , APPLICATION ACCEPTED BY DATE '"/ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSP CTION PHASE III FINAL INSPECTION <br /> INSPECTION BY !" _DATE INSPECTION BYVODATE <br /> ru 1nor Do„ 49_77 � 1_/78 2M <br />