Laserfiche WebLink
SAN JOAQUIN LOCAL'HEALTH DISTRICT <br /> FQR FFICE USE: 1601 E. Hazelton Ave.', Stockton, CA 95205 Permit� No. <br /> Telephone: (209) 466 -6781_ <br /> APPLICATIONJOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued �' �.3 <br /> This` Permit Ex ires 1�Year From Date. Issued <br /> Complete I,n 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 />'oanuin County Ordin g Ito. 186 and tie Rules and Regulations of the San Joaquin .Local Health <br /> /,1,A1 �� CITY T04 <br /> EXACT STREET ADDR 5S � � ' / <br /> Owner's Name r� <br /> A Phone <br /> Address <br /> /C C't <br /> + <br /> Contractor's Nam �1 Wiens <br /> IS CERTIFICATE OF WORKMAN S CdMPENSATIO"1 INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION El 'L ABANDONMENT ❑ OTHER❑ _ <br /> t� <br /> PUMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT <br /> p <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 /> In strial Cable Tool Dia. of Well Excavation A4 �) <br /> omestic/private i Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation tl�Gp`avel Pack Depth of Grout Seal_ <br /> Cathodic Protection i Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Insta ed �b/: <br />' PUMP INSTALLATION: Contractor �P. <br /> Type of Pump H.P. <br /> PUMP' REPLACEMENT: F]State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and ure <br /> I hereby certify that I havelprepared 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 a alifornia. " <br /> I WILL CAVL FOR A GROT,INSPECTIONyPR . IR TO OUTING AN NAL INSPECTION. DATE: " <br /> SIGNED TITLE. <br /> 44PL�N ON RE DE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> 'APPLICATION ACCEPTED BY _ DATE_f�-�3-78 <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION _ PHASE III FINAL INSPECTION <br /> ,INSPECTION BY DATE INSPECTION BY DATE G 7 <br />