Laserfiche WebLink
_ � 4 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT � <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , 'Stockton, CA 95205 Permi - <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date <br /> i <br /> This Permit Ex ires 1 Year From Date Issued <br /> Complete In Triplicate) <br /> Application is hereby made tojthe 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 />"oagt:in County Ordinance 1,U. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS D L&E oL CITY/TOWN <br /> Owner's Name ,lirl Phone <br /> Address - {.. city <br /> Contractor' s Name Li cense# 5` <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION! I1111_ A"SCE Oft FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check):., NEW WELL Q DEEPEN EJ RECONDITION C3 DESTRUCTION[] <br /> WELL CHLORINATION 0 WELL ABANDONMENT © OTHER 0 <br /> PUMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT E] <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 DOMESTIC WELL <br /> INTENDED USE ' TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private �� J Drilled Dia. of Well Casing �. <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 rrr r MC- <br /> Type t of Pump u,2 c -- H.1 <br /> ' I <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR. ' - QState Work Done — <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material an2 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." 11 <br /> I WILL CALL/FOR A GROUT INSPE ON PR RTO GROUTING AND A FINAL INSPECTION. <br /> ! AlAtrCk2- 01 <br />•SIGNED TITLEDATE: <br /> D AW PL PL N ON REVERSE SI <br /> y FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY <br />'ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE -III FINAL INSPECTION <br />,INSPECTION BY DATE INSPECTION B DATE�Zl <br /> C01/78 2M <br />