Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6781 l ' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued . -S-7� <br /> This Permit Expires I. Year From Date Issued <br /> Complete In Triplicate i <br /> Application is herebymade to the San �- <br /> Joaquin Local Hearth District for a permit to construct <br /> and/or install the work hereinldescribed. This application is made. in compliance with San <br /> 4oanuin County Ordinance No. 186.2 and the Rules and Regulations of the San Joaquin Local . Health <br /> District. <br /> EXACT STREET ADDRESS L � I:L 6 �If G� CITY/TOWN <br /> Owner's Name ` <br /> J v1 q Phone �S ��. ��•� <br /> Address S City_ <br /> Contractor's Name License# Phone <br /> IS CERTIFICATE OF WORKMAN'S COIMPENSATIO'N INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (, heck) : NEW WELLL DEEPEN 0 RECONDITION <br /> DESTRUCTION❑ � <br /> WELL CHLORINATION 0 -WELL ABANDONMENT p OTHER 0 ti <br /> PUMP INSTALLATION E] PUMP REPAIR❑ PUMP REPLACEMENT �i <br /> DISTANCE TO' NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> • PROPERTY LIN£ -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE f TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br />___F,- 4Domestic/private s Drilled Dia. of Well Casing � <br /> Domestic/public t Driven Gauge of Casing ' <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection i Rotary Type of Grout <br /> Disposal jl Other Other Information <br /> Geophysical �i Surface Seal Installed by* 1 <br /> PUMP INSTALLATION: Contractor <br /> r Type of PUMP , M.P. <br /> PUMP REPLACEMENT: State Work Done Is�1 <br />'UMP REPAIR: �' EDSta-t�e_,Work Done <br />)ESTRUCTION OF, WELL: Well- Diameter = Approximate Depth __ -_ 4 <br /> Des cr_i..be-Mate ria and Procedure S <br />[ hereby certify that I have prepared this application and that the work will be done in accordance <br /> Jith San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local <br /> iealth District. Home owner or licensed agent's signature certifies the following: <br /> It1,,cer:tify that-.i-n th'e-performance of the work for which this permit is issued, I shall <br /> not employ any person -in such manner a-s -to•`become subject to Workman's Compensation ' <br /> laws of*G-al�if_ornia."� � <br /> } <br /> WILL CALL FOR A GROUT INSPECTION PRIOR TO,-GRdl�TING AND A FINAL INSPECTION. ' <br /> 1 <br /> OIGNED-/- t TITLE: DATE: <br /> DR W PLOT PL N ON REVERSE SIDE <br />'HASE I FOR DEPARTMENT USE ONLY j <br /> iPPLICATION ACCEPTED -BY_�.4 y - Y T � - DATE <br /> IDDITIONAL COMMENTS: <br /> �--•PHASE -I-I -GROUT IN ECTION - - _ _ PHASE I I I- FINAL INSPECTION <br /> NSPECTION BY DATE INSPECTION BY DATE <br /> N-1426 Rev_ 12-77' -iQ 7r y <br />