Laserfiche WebLink
SAN JOAQUIN.LOCAL HEALTH DISTRICT <br />'IL12 FR FF„ICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. S,�d <br /> Telephone: (209.) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 5- 7 <br /> 6 <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. 06 ' <br /> EXACT STREET.ADDRESS CITY/TOWN, <br /> Owner' s Nantes Phone:y�� _s�. � � <br /> 'Address S/ c - W _ " City <br /> Contractor' s Name a License Phone2YP-2JM <br /> IS CERTIFICATE OF WORK'1AN'S COMPENSATION INSU ANCE ON FILE WITH SJLHD? YES NO � <br /> TYPE OF WORK (Check) : NEW WELLD6 DEEPEN II RECONDITION ® DESTRUCTION❑ <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER rJ <br /> PUMP INSTALLATION EI PUMP REPAIR❑ PUMP REPLACEMENT [1 { <br /> DISTANCE TO NEAREST: SEPTIC TANK ) i SEWER LINESS � PIT PRIVY <br /> SEWAGE DISPOS& FIELD . a{ CESSPOOL/S EP�IGE PIT OTHER <br /> ' -PROPERTY LINED-'4PRIVATE 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 s <br /> Irrigation Gravel ' Pac.k Depth of Grout Seal ` <br /> Cathodic Protection. . Rotary Type of Grout <br /> Disposal Other Other Information �. <br /> Geophysical Surface Seal Installed b <br /> PUMP INSTALLATION: Contractor­ <br /> Type of Pump H.P. , <br /> PUMP REPLACEMENT: O State Work. Done <br /> PUMP REPAIR: 0Sta-te-W0'_ Done <br /> DESTRUCTION-OF- WEE.L�: Wel I. Diameter Approximate Depth <br /> -' � Describe Material and Procedure <br /> I hereby certify that I have„ prepared this application and that the work will be done in accordan( <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Loca" <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 I <br /> not employ any person in such manner as to become subject to Workman's Compensation <br /> laws of California . " <br /> I WILL CALL F05 A ROU;?ASPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> 1 <br /> SIGNED TITLE:, 4a"-- DATE.: <br /> (DRAW PLOT PL N ON REVERSO SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APP.LICKTION ACCEPTED BY ZA—C DATE <br /> ADDITIONAL COMMENTS : � <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> F <br /> INSPECTION BY DATE INSPECTION BY DATE -1�-k6 <br /> CU in 0C D­ 5/79 2M I <br />