Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued. <br /> (tomplete , 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 o. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS <br /> CITY/TOWN � <br /> Owner's Name 'T ` Phone <br /> Address R o. _cl 7 City "C", a� . --- <br /> Contractor's Name U License#1�­ PhoneG- <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL CI DEEPEN ❑ RECONDITION DESTRUCTION[) <br /> WELL CHLORINATION Q WELL ABANDONMENT Q OTHER Q <br /> PUMP INSTALLATION [] PUMP REPAIRI8 RUMP REPLACEMENT Q <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 D MESTIC —WE-EF-- <br /> INTENDED <br /> EINTENDED 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 <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> —Geophysical-'- _r Surface Seal Insta ed <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: QState Work Done <br /> DESTRUCTION OF WELL: ' Well el Diameter _ -? <br /> _ — A�p�rc��c�mate Depth <br /> -Describe �ateria an Proce ure <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 licensediagent'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 mannerias to become subject to WW-kman's Compensation <br /> laws of California. " <br /> I WILL CA FO A GROUT NSPECTION PRIOR`TO GROUTING AND A F <br /> SIGNED INAL INSPECTION. <br /> TITLE: DAT E:J '�a3 -, <br /> DR W PLT L N ON REVERSE IDE <br /> PHASE I R D RT EIT USE ONLY �✓ <br /> PPS LICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II ROUT- INSPECTION <br /> INSPECTION BY PHASE III FINAL INSPECTION <br /> .DATE IN ON BY DATE �7 <br />£H 1 26 Rev. 9/ a �' 9178 2M <br />