Laserfiche WebLink
" SAN JOAQUIN LOCAL,HEALTH"'DISTRICTFOR . <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton,'� CA 95205 Permi=?k6 <br /> No.Telephone: ' (209) 466417.81 -APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date <br /> This Permit Ex s .l Year From Date Issued <br /> ire <br /> Y Complete In Triplicate <br /> Application is hereby made to the San Joaquin Local Health District for a' per mit to construct . <br /> and/or install the work herein described. This application is made in compliance with San <br /> ,loaqui n County Ordinance �Io. . 1862 and. the Rules and •Regulations of the San Joaquin Local. Health <br /> 5istrsct. <br /> EXACT STREET ADDRESS 6 CITY/TOWN <br /> �Owner' s Nam Phone <br /> �_.. Ci ty .. 4_1 <br /> Address. .. i <br /> Contractor' s Name <br /> License Phon <br /> Zd <br /> 3 <br /> IS CERTIFICATE OF WORK�3A�Pd'S COMPENSATION INSURANCE OM FILE WITH SJLHD? YES Z� NO <br /> .. <br /> LTYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ PRECONDITION [3 DESTRUCTION d <br /> t. WELL CHLORINATION WELL ABANDONMENT ❑ OTHER❑ _ _ O <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT <br /> P <br /> [] <br /> DISTANCE TO NEAREST: SIEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> i PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> OM <br /> w INTENDED USE I 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 r Other Information <br /> Geophysical Surface Seal Installed by: <br /> a <br /> PUMP INSTALLATION: Contractor' ' �• <br /> Type of Pump s..a a H.P. <br /> PUMP REPLACEMENT: State Work Don w ' <br /> PUMA REPAIR: ; ft tate Work 1i Ett -00 0r <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth- <br /> Describe Materia an Procedure <br /> I. <br /> I <br /> I hereby certify that I have prepared this application and that theawork will be done in accordanc <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 GROUTMINSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> IN TITLE: DATE: <br /> SIGNED <br /> OR W PLOT PL -N ON REVERSE SIDE <br /> FOR DEP RTMENT USE ONLY <br /> PHASE I DATE . 7 <br /> APPLICATION ACCEPTEDBY <br /> ; ADDITIONAL COMMENTS: i� <br /> PHASE II' GROUT: INSPECTION. PHAS IallL INSPECTION <br /> INSPECTION BY IN DATE INSPECTION BY DATE <br /> ­2M_ W _ <br />