Laserfiche WebLink
FFICE USE: SAN JOAQUIN LOCAL HEALTH DISTRICT, <br /> 160 . Hazelton Ave. , Stockton, CA . ,205 Permit No. ] <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued a Z-,29 <br /> ('Complete In Triplicate) ��PX� 7� /y 3 <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. Z J <br /> EXACT STREET ADDRESS J�3 Y �^�—t;�" CITY/TOWN rzSG <br /> Owner's Name �] Phone <br /> Address 2-323City <br /> Contractor's Name U ren ��- License# 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❑ L% <br /> WELL CHLORINATION [J WELL ABANDONMENT E7 OTHER 0 <br /> PUMP INSTALLATION-CR PUMP REPAIR O PUMP REPLACEMENT C) � <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSP L/SEEPAGE PIS OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC D MESTIC WE L- <br /> INTENDED USE TYPE OF WELL. CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of We Excavation <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 /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor 0-3 ML <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: M State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> 'DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materidi and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordan <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Loca <br /> Health District. Home owner or licensed agent's signature certifies the following: <br /> 1 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 CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: <br /> DR W PL T L N ON REVERSE SIDE <br /> 'RASE I R DEP RTMENT USE ONLY <br /> PP�-LICATION ACCEPTED BY llzDATE <br /> 1DDITIONAL COMMENTS: <br /> PHASE II GROUTINSPECTION ' PHASE III 5INAL INSPECTION <br /> NSPECTION BYE_ DATE Z/14- - INSPECTION BY <br /> .H 14 26 Rev. 9/78 DATE vZ_��( <br /> Q/7A 9M <br />