Laserfiche WebLink
i K " +e <br /> SAN JOAQUIN LOCAL,-HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Expires I Year FrorrDate 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 />%loapuin County Ordinance -No. . 1862 and the Rules and . Regulations of the San Joaquin Local Health <br /> District. n r' <br /> EXACT STREET ADD RESS CITY/TOWN ,(� 6+ <br /> Owner's NameAN 14A t 4 Phone_ ,, <br /> Address Cit <br /> y=-- CL <br /> i4C V <br /> Contractor's Name 19AI, cense � / Phone J?Y <br /> IS CERTIFICATE OF-WORKt1AN'S-COMPENSATIO"I"lt4SURAIIIC 0:�1.. .FILE-:WITH-SJLHD?'- - YES NO <br /> TYPE OF WORK--"(-Check) ' NEW WELL[M —_DEEPEN ❑- '_RECON'DITION:C]' aDESTRUCTION�� = - <br /> WELL--CHLOR)`NATION,Q WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION Cl 'x PUMP REPAIR❑ PUMP REPLACEMENT EJ <br /> DISTANCE TO NEAREST: SEPTIC TANK { SEWER LINES:,So ,k PIT PRIVY <br /> SEWAGE DISPOSAL IELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINA' L.*RIVATTE6'E�DDO ESTIC`�WELL,?�: PUBLIC DOMESTIC WELL <br /> INTENDED USE ' TYPE-0E-WELL' -CONSTRUCTION SPECIFICATIONS <br /> Industrial . Cable Tool ,Dia:"of Well Excavation <br /> Domestic/private Drilled i Dia. of Well Casing 9/ <br /> Domestic/public DrivenL fGauge,of Casing�l r" <br /> Irrigation I ... :; �_Gr-avel -Pack' µ Depth` of, Grout Seal��s / <br /> Cathodic Protection Rotary Typelof Grout <br /> Disposal rOther Other Information <br /> Geophysuital-- Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> _. - Type of Pump r H. . <br /> 4 t <br /> PUMP REPLACEMENT: p State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well, Diameter Approximate Depth _� -.� <br /> Describe Materia an-a Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordance <br /> Mith San Joaquin County Ordinances, State Laws , and Rules and Regulations of the San Joaquin Local <br /> lealth" 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 NS CT PRIOR TO GROUTING AND A FINAL INSPECTION. <br />;IGNE TITLE: �.� DATE: Pz az <br /> DR W PLOT PL N ON REVERSE SIDE <br />'BASE I FOR DEPARTMENT USE ONLY <br /> IPPLICATION ACCEPTED BY__..2J DATE Id //7/4 <br /> kDDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> NSPECTION BY _ DATE INSPECTION BY � DATE <br /> -f - <br /> H,.1.4261 �Rew.' 12=77 -im r <br />