Laserfiche WebLink
r 'AN JOAQUIN LOCAL HEALTH DISIR10' - <br /> EQR OFFICE USE: 1601 E. Hazelton Ave. .' Stockton, CA 95205 Permit No.7 h4( . <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Expires 1 Year From Date Issued <br /> Complete In Triplicate <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> +nd/or install the work herein described. This application is made in compliance with San <br /> r.oaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> :XACT STREET ADDRESS �` _t �/� _ CITY/TOWN _ r <br /> `hwner's Name uy Va v Phone - ( _ <br /> address ` ' City, e e;-; <br /> "Contractor' s Name License J ' Phone <br /> IS CERTIFICATE OF 14ORK"iA"d'S CO,"iPENSATIO"J Il" SURANCE I FILE WITH SJLHD? YES NO <br /> `TYPE OF WORK (Check) : NEW WELL j 'j DEEPEN ❑ RECONDITION E] DESTRUCTION[] <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER ❑ <br /> r <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK-,c-� r+ SEWER LINE 1 PIT PRIVY <br /> SEWAGE DISPOS L FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINEU�+PRIVATE DOMESTIC WELLPUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation / 9 fi <br /> - _Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing e-'/A <br /> Irrigation Gravel Pack Depth of Grout Seal_ S0 j <br /> Cathodic Protection Rotary Type of Grout_ ,Cadc",t `' <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> SUMP 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 accordar <br /> -with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Loci <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 California." <br /> I WILL CA R A GR UT ASPVXON PRIOR TO GROUTING AND A FINAL INSPECTION. If <br /> .SIGNE TITLE: eakAi DATE: / <br /> DRAW PLOT PLAN ON REVERS SIDE <br /> FOR DEPARTMENT USE ONLY <br /> ..PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: 14 <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY i DATE INSPECTION BY & DATEI <br />