Laserfiche WebLink
�• w <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br />_�QR OFFICE USE`: 160.1-.J. 'Hazelton Ave. ,' Stockton, CA 95205 Permit No'!-Z.1 <br /> Telephone: (209) 466-6781 <br /> `! APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued - '-7 <br /> ThisPermit Ex ires ..1 Year. From Date Issued <br /> Pr 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 here N described. This application is made in compliance with San <br /> Joaquin County Ordinance No. 1.862 and the R s and Regulations of the San Joaquin Local Health <br /> District. <br /> a <br /> EXACT STREET ADDRE Q . S _CITY%TOWi <br /> t <br /> Owner's Name -i phone <br /> Addres-s l <br /> C i ty <br /> Contractor35, Na�le�. � ' r, License# Phone 2Z .�1 F <br /> IS CERTIFICATE OF WORKf1AN'S COM E:NSATIO"1 INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> f� WELL CHLORINATION ❑ WELL''ABANDONMENT ❑ OTHER F-1N <br /> _ ,PUMP INSTALLATION 0 PUM6 REPAIRO PUMP REPLACEMENT ❑ � <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> k PROPERTY LINE -, PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDEDr'IUSE TYPE OF WELL CONSTRUCTION SPECIFIC IONS <br /> Industrial Cable Tool Dia. of Well Excavation S <br /> Dome"stic/private Drilled Dia. of Well Casing F <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic .'iProtection Rotary Type of Grout <br /> Disposal i Other Other Info;rmation G <br /> Geophysiclal _ <br /> ---Surface Seal Instal ed <br />)UMNSTALLATION: Contractors <br />)UMP/INSTALLATION: <br /> f- Type of,;Pump H.P: <br />)UMP,RE•PLACEM£NT: ❑State Work Done <br />)UMP REPAIR: ❑Stag Work Done <br /> k � <br />)ESTRUCTION #OF WELL: Well Diameter ' Approximate Depth <br /> Describe.-Mater-i-a - and Procedure <br /> t <br /> hereby certify that I have prepared this application and that the work will be done in accordance <br /> lith San JoaquinlCounty Ordinances, State Laws , and Rules and Regulations of the San Joaquin Local <br /> leaf th Di stri c,t.lHome owner or. 1 icensed_agent'.s .signature certifies the ,fol lowing: <br /> "I certify that in the perfo mance of the work for which this -permft`-is issued, I shall <br /> not employ;any person 11 �in such manner as to become sub 'ect to Workman"""' Compensation <br /> laws of Clifornia.- <br /> WILL CALL FAR`A GROIN INSPECTI PRIOR.,.TO GROUTING A A F NAL INSP. C ON ' ` <br /> IGNEDTITLE: DATE: <br /> MRAW PLOT PITNT ON REVER SIDE: <br /> RASE I FOR DEPARTMENT LYSEIIKY <br /> PPLICATION ACCEPTED BY <br /> DATE -° -Z, <br /> DDITIONAL COMMENTS: <br /> PHASE II QROUT INSPECTION PHASE III <br /> FI AL INSPECTION <br /> NSPECTION BY DATEs � _ INSPECTION BY Y DATE_ _ ' <br /> `�'��Q �M <br /> 1 1426 ' Rev. 12-77' <br />