Laserfiche WebLink
F' <br /> SAN JOAQUIN LOCAL HEALTH DISTDT.CT hermit N .'? <br /> FF"I'�E USE. ,,,,E. Hazelton Ave. , Stockton, 95205 <br /> Telephone: (209) 466-6781 tir'- <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 /> ,oaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. cc�� <br /> EXACT STREET ADDRESS d Q �� /VPV Uf CITY/TOWN TO, <br /> Owner' s Name �l C6Jy CQF_ .T. Phone '� ��E �s oN � � ��V C��_ <br /> Address 0S2 M4y V h 2 <br /> city _-5T© <br /> Contractor' s Name_ Nm 4[-� 6;QeS. AQ W;� V k Li cense# yqvs/13 Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURAINCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check).: NEW WELL'91 DEEPEN❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER Q <br /> PUMP INSTALLATION C1 PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: ASEPTIC TANK SEWER LINES PIT PRIVY <br /> fcwe/�' SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> j{ Industrial Cable Tool Dia. of Well Excavation r O <br /> Domestic/private Drilled Dia. of Well Casing 1AD9 <br /> Domestic/public Driven - Gauge of Casing //r, <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout P_ T_ <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <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 Materia and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordi <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Loc <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 GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE:�6 6 29 <br /> DRAW PLOT PLAN ON REVERSE S DE <br /> FO EPARTMEN T USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: 4�i_ <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY (--) DATE -174/90 <br />