Laserfiche WebLink
SAN JOAQUIN LOCAL HLALIH UISIRICI <br /> FFICE USE: 1601 E. HazeltonAve. , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-678I <br /> b APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued� '/7"7 <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 in compliance with San <br /> .'oaquin County Ordinance No. 1862 and the Rules and Regulations of the .San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS /,5'y1 Uv CITY/TOWN di <br /> Owner's Dame <br /> Mcg ej Sc A Phone J? --_a d z--Z_ <br /> Address 30q � Ci.t . <br /> . <br /> Contractor's Name s et ✓ e License# Phone--, 3 <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES `" NO <br /> TYPE. OF WORK (-Check) : NEW WELL U DEEPEN 0 RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION <br /> ❑ WELL ABANDONMENT O OTHER 0 4:PUMP INSTALLATION � PUMP REPAIR 0 PUMP REPLACEMENT <br /> Q <br /> DISTANCE TO NEAREST: SEPTIC TANK� SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINEA4'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 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 140'1 r e95'41 v zr� ,- <br /> Type of PumpcR�6 _ H. SQ <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe MatJial 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 /> "II certify that in the performance of the work for which this permit is issued, I shall <br /> not employ o <br /> p y an y person in such manner as to become subject to Workman's Compensation <br /> laws of California. " <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE. DATE; <br /> DR W PLOT PL NON R RSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> .� <br /> EH 1426 Rev. 12-77 1178 2M <br />