Laserfiche WebLink
t SAN JOAQUIN' LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> ,. Telephone: (209) 466-6781 a <br /> Date Issued <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <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 /> , Joaquin County Ordinance, No'. 1862 and the Rules and Regulations of the San Joaquin Local Health . <br /> District. <br /> , EXACT STREET ADDRESS 1 Sk ZZ4LIff I 1U _ Q ff' CITY/TOWN-AC,AM PQ _ <br /> i Owner's Name t AJ.5 1&Z.2,0 Phone <br /> Address City -- <br /> Contractor's Name R ILL I {V Li cense#S4M QZ Phone <br /> i, IS CERTIFICATE OF WORKMAN'S COMPENSATIOt! INSURAINCE ON FILE WITH SJLHD? YES X NO <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION ❑ DESTRUCCT10N❑ <br /> a WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTE F _ - <br /> PUMP INSTALLAtON E PUMP REPAIR❑ PUMP REPLACEMENT [� <br /> ,/ Ali. W''h.+: <br /> DISTANCE TO NEAREST: SEPTIC TANK' ® - '•'SEWER LINES —� PIT PRIVY IV l - o� <br /> i SEWAGE DISPOSALS FIELD- -CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -, PRIVATE,-'DOMESTIC WELL6Z2=1'PUBLIC DOMESTIC WELLtiL4- <br /> r <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 11"A <br /> Irrigation ^Gravel Pack Depth of Grout Seal <br /> CathodicProtection X Rotary Type of Grout O&W if <br /> Disposal Other Other Information I <br /> Geophysical .. Surface Seal Instal ed b :11 <br /> PUMP INSTALLATION: Contractor <br /> . Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: O State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Al 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 accordant <br /> i 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 GROU INSP CTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: <br /> DR W PLOT PL7N ON REVERSE SIDE EI <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> , INSPECTION BY DATE INSPECTION BY DATE - <br /> ! FN 1Q7F An., 19_7.7. - / 1/7$` 2m- <br />