Laserfiche WebLink
} <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. - �y <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued �� <br /> r <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 incompliance 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 Phoned�"- � 1 _ j <br /> Address I—W Ci ty <br /> License# <br /> Contractor' s Name ���- . ��,�� � _._ �-,;� Phone .,��x_" <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES NO If <br /> TYPE OF WORK (Check) : NEW WELL Q DEEPEN 0 RECONDITION ❑ DESTRUCTION(D OSI <br /> WELL CHLORINATION WELL ABANDONMENT 0 OTHER 0 _ Cr <br /> PUMP INSTALLATION PUMP REPAIR 0 PUMP REPLACEMENT L� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> . PROPERTY LINE . PRIVATE DOMESTIC WELL PUBLIC DOME STIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casings <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 <br /> Type of Pump ,�'m �!��.'h - - H.P. <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: w ❑State Work Done <br /> DESTRUCTION OF WELL: Well 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 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 GROUT INSPE ION PRIOR TO GROUTING AND A FINAL INSPECTION. <br />"SIGNED TITLE: � DATE: <br /> DRAW PLOT PL N ON REVERSE SIDE) <br /> FOR DEPARTI4EN USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br />' ADDITIONAL COMMENTS: <br /> PHASE_II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BYDATE INSPECTION BY •,J DATE <br /> a% <br />