Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH <br /> HISTRRIC95205 Permit No. <br /> . FFICE USE: 1601 E. Hazelton Ave. , Stockton, <br /> Telephone: (209) 466-6781 pate Issued -APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit Ex ires 1 Year From Date Issued <br /> Complete In Triplicate <br /> is hereby made to the San Joaquin Local . Health District. for a permit to construct <br /> Applicationapplication is made in with San. <br /> and/or install .the work herein described. This app ; <br /> in Count Ordinance No. 1862 and the. Rules and Regulations of the San Joaquin Local Health i <br /> Joaqu Y ; <br /> !District. CITY/TOWN <br /> EXACT 'STREET ADDRESS 4 Phone (z <br /> '33 <br /> Owner' s <br /> �.. <br /> Owner' s Name City <br /> Address <br /> Li cense .2.� Phone <br /> Contractor's Name <br /> IS CERTIFICATE OF 1JOf'KMAN'S COMPENSATIO"� I��SURANr.F ON FILE V1ITH SJLHD? YES <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN RECONDITION <br /> C C! DEOTRUC ❑N[2 <br /> WELL CHLORINATION ❑ ,� <br /> PUMP INSTALLATION ❑ PUMP REPAIR 8 PUMP REPLACEMENT C� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY _ OTHER_r_____ <br /> SEWAGE OISPOSAL FIELD CESSPOOL/SEE <br /> PROPERTY LINE -, PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL Ns <br /> + TYPE=OF WELL CONSTRUCTION SPECIFICATIONS <br /> i INTENQED USE Cable Tool Dia. of .Well Excavation <br /> IndustrialDrilled, Dia. of Well Casing <br /> i - Domestic/private Gauge of Casing <br /> Domestic/public - Driven <br /> i Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> 7 -Other 4 Other`'Informat�on <br /> - -Di s-po-s-al -- - '� - Surface Seal Instal 1 ed by: <br /> Geophysical <br /> t PUMP INSTALLATION: Contractor H.P. _ <br /> Type of Pump <br /> PUMP{ REPLACEMENT: State Work Done <br /> r PUMP REPAIR: "Mate Work Done P <br /> Approximate Depth <br /> pESTRUCTION OF WELL: DescrDibell mMateria an 1:11,,cicei ure <br /> i <br /> I hereby certify that I have prepared this pliandion Rulesand <br /> andthat <br /> Regulat�onswill <br /> the Sandone <br /> Joaquino <br /> rdar <br /> Ordinances, State Laws, <br /> Loca <br /> with San Joaquin County Or <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." 2 <br /> I WILL CALL FJA A GROUT INSPECTION PR RfTO GROUTING A A FINAL INSPECTION• DATE: <br /> SIGNED TITLE: <br /> DR W PLOT PL N ON REVERSE DE <br /> FOR DEPARTMENT USE ONLY <br /> I PHASE I DATE <br /> APPLICATION ACCEPTED BY if d3 • �. <br /> ADDITIONAL COMMENTS: PHASE III FINAL INSPECTION <br /> PHASE II GROUT INSPECTION ,- DATE <br /> kINSPECTION BY DATE INSPECTION BY <br /> 1 /78 2I <br />