Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F��FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> - egI7 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued ,-1- 7� <br /> This Permit. Ex ires 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 /> 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 ADDRESS ;2 7 7 /L.d� CITY/TOWN <br /> Owner's Name Phone 3 �� <br /> Address 7 City <br /> Contractor's Name License#fPhone_3 <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION! INSURA,110E ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN 0 RECONDITION DESTRUCTION[j <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER 0 _ <br /> PUMP INSTALLATION C] PUMP REPAIRE4 PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> • PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL G� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed b : rl <br /> PUMP INSTALLATION: <br /> Contractor <br /> Type of Pump H.P. -- <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: E45tate Work Done �. <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Proce ure <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 California. " <br /> I WILL CALL FO A GROUT I PECTION P OR TO GROUTING AND INAL INSPECTION. <br /> SIGNED TITLE: DATE: r <br /> RAW PLOT PLTN ON REVERSE SI <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE (/,.,-) <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY Z �. DATE <br />-EH 1426 Ray. 12-77 1 1-70 n" <br />