Laserfiche WebLink
SAN JOAQUIN. LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.)f//, 7,3 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL .CONSTRUCTION OR PUMP PERMIT Date Issued,/, <br /> This Permit Ex ires .l Year From Date Issued <br /> Complete In -Triplicate) ' <br /> i <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 /> k'oaauin County ordinance No. 186 aril the Rules nd Regulations of -the San. Joaquin Local Health <br /> District. �;e S� So, <br /> EXACT 'STREET ADDRESS �E3�^�D✓ fJ� kJ CITY/TOWN <br /> Owner' s Name //ePhone <br /> Address 0 City. <br /> Contractor's Name -s License# Phone o <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO"1 INSURA"SCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN Q RECONDITION ❑ DESTRUCTIONEJ <br /> WELL CHLORINATION 0 WELL ABANDONMENT p OTHER <br /> PUMP INSTALLATION j4 PUMP REPAIR❑ PUMP REPLACEMENT ❑ f <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES -' PIT PRIVY O� <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL, CONSTRUCTION SPECIFICATIONS 4- 1 <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 by: _ <br /> PUMP INSTALLATION: Contractor Al f_-_s <br /> Type of P mp Alit < H.P. <br /> PUMP REPLACEMENT: [] State Work Done <br /> PUMP REPAIR: ❑State Work Hone <br />'DESTRUCT16N"10F'"WELI..—W Tl``Diameter— _. ._-��_._ _._.._- -App-roximate-Depth <br /> Describe Material an2 Procedure <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 GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED -- . TITLE : 01 DATE: <br /> DR W 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 I XPHASE114 INAL JNSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE Z <br />