Laserfiche WebLink
SAN JOAQUIN LOCAL .HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave ' , Stockton, CA 95205 Permit Na. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTIONORPUMP PERMIT Date Issued <br /> This Permit -Expires 1Year From <br /> Date Issued <br /> Complete In Triplicate <br /> Application is hereby made to the San Joaquin Local Health Di.str'ict fore permit to construct <br /> land/or install the work herein described. This application is made in compliance with San <br /> ,.'oaq,,iin -County Ordinance Noj 1862 and the Rules and Regulations of the.,San Joaquin Local Health <br /> r)i strict. <br /> EXACT STREET ADDRESS �: �%�7 <br /> 'CITY/TOWN e <br /> Owner's Name Phone <br /> Address `� 'City <br /> Contractor's Name ,yam License# /" Phone <br /> ' IS CERTIFICATE OF WORKMAN'S COMPENSATION! i1111SUR -CE ON FILE WITH SJLHD? YES � NO <br /> TYPE OF WOR K" (Check} : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ <br /> Yt PUMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT ❑ t� <br /> , DISTANCE TO NEAREST: SEPTIC TANK�'�SEWER LINES rf PIT PRIVY r— <br /> SEWAGE DISPOSAL FIELDS C SPOOL/SE PAGE PIT to7D t7HER <br /> PROPERTY LINE/P'PRIVATE DOMESTIC WELL -r PUBL C 'DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> 1,-- Domestic/private «frilled Dia. of Well Casing <br /> F Domestic/public Driven - Gauge' of Casing Z57 � _ __ <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 /> JPUMP INSTALLATION: Contractor r ! 1' <br /> Typel`of Pump N• . <br /> PUMP REPLACEMENT: ]State Work Done <br /> . PUMP REPAIR: ❑State 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 accordan <br /> with San Joaquin County Ordinances , State Laws , and Rules -and Regulations of the San Joaquin Loca <br /> lHealth 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 ire such manner as to become subject to Workman's Compensation . <br /> laws of California. " <br /> � I WILL CALL-EQ1A qRQUTINSPECTION PRIOR TO GROUTING A-ND'.A. FINAL INSPECTION. <br /> k <br /> SIGNED ITLE: �, DATE: <br /> W�RLOT—PL. N ON-.REVERS .SIDE <br /> FOR DEPARTMENT USE ONLY <br /> 'PHASE I <br /> APPLICATION ACCEPTED B1 iCSN C-A <br /> DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT H NSPECTION PHASE III FINAL INSPECTION <br /> iINSPECTION BYiDATE INSPECTION BY DATE % <br /> pPW I a99 Do„ 19-77 _ 1/78 2M <br />