Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> -.OFFICE E USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 46676781i� <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 /> and/or install the work herein described. This application is made in compliance with San <br /> 1-oaouin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS CITY/TOWN ll� ,0 Ci <br /> Owner's Name Phone !2,5ek ry— _ <br /> Address <br /> Contractor's NamerAic License " j Phone�'f_�,p/ <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO"J TN-,11RA•10E ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL M DEEPEN ❑ RECONDITION ❑ DESTRUCTION <br /> —"'W£Lt CHL" IINATION ❑- - WELL ABANDONMENT -Q,----OTHER-#J-�— <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC -TANK&f -- SEWER LINES/ /4 PIT PRIVY <br /> SEWAGE DISPOSAL fFIELD fD'� CESSP0 L/SEEPAGE PIT OTHER <br /> � <br /> PROPERTY LIN .fPRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS' <br /> Industrial Cable Tool Dia. of Well Excavation <br /> --42 <br /> Drilled Dia. of Well Casing 11 <br /> Domestic/public Driven , — Gauge of Casing f f.�sc <br /> Irrigation =Gravel Pack Depth of Grout SP f <br /> Cathodic Protection _ y Rotary Type of Grout <br /> Disposal Other '—­Y��Oth­ffr Information <br /> Geophysical Surface Seal Installed b <br /> PUMP 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 —i-0 <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 FOR A OUT INSPECTAON PMR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE:~ <br /> PLOT PLAN ON REVERSE DE \ <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III 4INAL INSPECTION <br /> INSPECTION BY ;b I DATE4412INSPECTION BY �J7 DATE �- 7 �! <br />_EH 1426 _'Rev. 12-77 __ 1 '179 2M <br />