Laserfiche WebLink
MQFICE <br /> SAN JOAQUIN LOCAL-- HEALTH DISTRICT <br /> USE: 1601 E. Hazelton Ave: ; Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6781 G <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date issued <br /> This- Permit Ex i.res 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 /> Joaquin- County Ordinance No. 1862- and the= Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESSCITY/TOWN ,,. <br /> Owner's Name Phone <br /> Address Cityi <br /> Contractor' s Nam License#gi 2 k Phone G y b R! <br /> IS CERTIFICATE OF WORKMAN'S COMP S TIO-11 Ii1SURA"!CE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN ❑ PRECONDITION [3 DESTRUCTIONE3 <br /> WELL CHLORINATION Q WELL-ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION 0 PUMP REPAIR(O PUMP REPLACEMENT [] <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> 'SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER o� <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <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 Sea <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of PumpH.P. <br /> PUMP, REPLACEMENT: []State Work Done <br /> PUMP REPAIR: 3OState Work Done Algo* /0 re ioao4t <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materia a-rid 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 INS TI P OR GROUTING AND A FINAL INSPECTION. <br />!� <br /> S I G N E ITLE: DATE: 1-f� <br /> j(DRAW- PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY_Az DATE Z&' <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE _IIj, FINAL- INSPECTION <br /> NSPECTIp ''BY DATE INSPECTION BY DATE <br /> I, FH 1 d 9 A Rav�'1'`1-77 51 7M <br />