Laserfiche WebLink
SAN JOAOUIN LOCAL HEALTH DISTRICT <br /> DICE USE: 1601 E. Hazelton A-ve. , Stockton, CA 95205 Permit No. <br /> Telephone: ' (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit-Expires 1 Year. From Date Issued IkWZ4, a <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 /> ,oaQ-,,Jn County Ordinance "o. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> 'Distract. / <br /> EXACT STREET ADDRESS f7 CITY/TOWNC� - <br /> Owner' s Name .,,;14 ,, Phone <br /> Address �r Z T - City <br /> Contractor' s Name Li cerise# /✓r�.�Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES N07 <br />` TYPE OF WORK (Check) : NEW WEL� DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT p -OTHER 0 <br /> PUMP INSTALLATION DO PUMP REPAIR❑ PUMP REPLACEMENT ❑ W <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 Drilled Dia. of Well Casing <br /> omestic/public Dri.;yen - Gauge of Casing s <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` ` <br /> Type of PumpH.P. <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 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 /> f "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 CA4k-TUR`— ECTkQN PRIOR TO GROUTING AND A- FINAL INSPECTION. <br /> SIGNED TITLE : DATE: <br /> .4 a?� <br /> L-=-AW PLOT PLAN---ON REV£ SE ID <br /> PHASE I <br /> Fgk DEPARTMENT USE ONLY <br /> 4ADDIE <br /> APPLICATION ACCEPTED BY DATE )Y74- <br /> ADDITIONAL <br /> TIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION -PHASE I NAL INS ECTION <br /> INSPECTION BY DATE INSPECTION BY VT.E-_4 <br /> F EH 1426 Rev. 12-77 1/78 2M <br />