Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> -r OR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT I <br /> Date Issued 11-16-,2r <br /> (,Complete In Triplicate) <br /> arpplication 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 /> aquin County Ordinance No. 1862 and the Rules pd Regulations of the San Joaquin Local Health <br /> [_strict. i _��7 A/. Tvrev� Y� <br /> FXACT STREET ADTRESS CITY/TOWN <br /> ;_per's Name C- Phoned f �, �_Z`7 <br /> 4ddress 0U Ci ty <br /> ntractor's Name /(� � � Li cense#/(-217 3 Phone <br /> IS CERTIFICATE OF WORKMAN'S CO'�PENSATION INSURANCE ON FILE WITH SJLHD? YES NO <br /> 1 PE OF WORK (Check) : NEW WELL DEEPEN 0 RECONDITION ❑ DESTRUCTION❑ � <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ y <br /> PUMP INSTALLATION fa PUMP REPAIR❑ PUMP REPLACEMENT ❑ (14 <br /> )TSTANCE TO NEAREST: SEPTIC TANK 16-b' SEWER LINES Zoo ' PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSP OL/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 /> _ a " <br /> Domestic/private Drilled Dia. of Well Casing , <br /> — Domestic/public Driven Gauge of Casing 1--2- <br /> Irrigation <br /> --2-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 /> MP INSTALLATION: Contractor 4 <br /> Type of Pump H.P. <br /> "'MP REPLACEMENT: ❑State Work Done <br /> _MP REPAIR: ❑State Work Done <br /> )FSTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> hereby certify that I have prepared this application and that the work will be done in accordanc <br /> th San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local <br /> ffalth 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 /> WILL CAL OR A GROUT INSRECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> GNED TITLE: DATE: <br /> ItADRAW PLPLAN' ON REVERSE DE <br /> ASE I FOR DEPARTMENT USE ONLY <br /> 7PLICATION ACCEPTED BY C . 13• DATE <br /> ,nDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION„ <br /> 7 SPECTION BY -^ DATE INSPECTION BY . i3 DATE_ 1,4L 31-7f <br />