Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH 'DISTRICT <br /> FICE USE: 1601 E. Hazelton Av`e. , Stockton; CA 95205 Permit No.1 <br /> Telephone: ili (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR- PUMP PERMIT Date Issued <br /> This Permit Expires. I Year. From Date Issued <br /> Comp1 e t e- In Triplicate l 73 - 2-co- ?� ` <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 /> ucaQuin County Ordinance No. _1862' and the Rules and Regulations- of the San Joaquin Local Health <br /> EXACT STREET ADDRESS Ss �. CITY/TOWN <br /> Owner's Name Phone <br /> Address ��' !L-s f� Ci:ty C� ?'�. 4 <br /> Contractor' s Name y �� License# 3 Phone <br /> IS CERTIFICATE OF WORKHAN'S CI�W, NSURA. NCE ON FILE WITH SJLHD? YES,, NO <br /> TYPE OF WORK (Check) : NEW WELL M DEEPEN 01 RECONDITION Q DESTRUCTION[1 <br /> WELL CHLORINATION Q WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION 0 k Pi UMP REPAIRPO PUMP REPLACEMENT <br /> DISTANCE TO=NEAREST: SEPTIC TANK SEWER', LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD IN CESSPOOL/SEEPAGE PIT OTHER " <br /> ! PROPERTY LINE -. PRIVATE, DOMESTIC WELL PUBLIC DOMESTIC WELL I <br /> INTENDED USE -„,,., _ TYPE ,OF WELL CONSTRUCTION SPECIFICATIONS � <br /> Industrial .. Cable Tool Dia. of Well Excavation M 4 <br /> Domestic/private Drilled Dia. - of Well Casing <br /> Domestic/public Driven . , Gauge of Casing <br /> Irrigation } Gravel Pack:. Depth of. Grout Seal <br /> CathodiO Protection Rotary Type of Grout <br /> Disposal Other i Other Information <br /> GeophysicalSurface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type.o:f.Pump H.P. hit, 4, <br /> PUMP REPLACEMENT: <br /> []State Work Done <br /> PUMP REPAIR: .�' State Work Done a ,f ,V <br /> 161 •I <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> ” Describe Material and 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't and Rules and Regulations of the San Joaquin Local i <br /> Health District'.. . Home owner or licensed agentiMs 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 tobecome subject to Workman 's Compensation <br /> laws of California." ` <br /> I WILL CALL FOR A GROUT-INSPECTMN PARI TO ROUT NG AND A FINAL INSPECTION. <br /> S IGNED . -'0 <br /> r�1` . - DATE <br /> D P T PLAN CW REVERSE SIDE <br /> F R DEPARTMENT USE ONLY <br /> PHASE I f <br /> APPLICATION ACCEPTED BY ! DATE 7-/d • '�^� <br /> ADDITIONAL COMMENTS : i� <br /> PHASE Ii GROUT INSPECTION f PHASE III FINAL INSPECTION <br />[NSP>=CTION BY DATE I INSPECTION BY DATE <br />