Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT ` <br /> FFICE USE: 1601, E. Hazelton Ave. , Stockton, CA 95205 Permit No.7F7-14 9/ <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <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 /> .'oanuin County Ordinance 1,+o. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS � � CITY/TOWNr U L _ <br /> Owner' s Name C o Phone <br /> Address City_ �c�c .� <br /> Contractor' s Name License#1 5010 Phone W �, 1.6 �q:_ <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION IiISURA^ICE ON FILE WITH SJLHD? _ _YES 1 NO <br /> IN <br /> TYPE OF WORK (Check) : NEW WELLU) DEEPEN G RECONDITION ® DESTRUCTION[] <br /> WELL CHLORINATION p WELL ABANDONMENT p OTHER 0 <br /> PUMP INSTALLATION I& PUMP REPAIR❑ PUMP REPLACEMENT [ � , <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 i�DriIIed Dia. of Well Casing ► <br /> Domestic/public Driven Gauge of Casing f- <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 ar 1 —Vz- � . <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: [I State Work Done <br /> PUMP REPAIR: QState 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 A GRWJT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: <br /> DATE: <br /> N DR W PLOT PL ES E <br /> FOR <br /> DEPARTMENT USE ONLY <br /> PHASE I j <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: - <br /> PHASE II GROUT I SPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BYZ)& DATE .— <br /> EH 1426 Rev. 12-77 LbA 33 -- - -_ _ 1/7802M <br />