Laserfiche WebLink
F��JFICE <br /> `. SAN- JOAQUIN LOCAL HEALTH DISTRICT <br /> USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.Tg-/.)_:.L� <br /> Telephone: (209) 466-6781 <br /> -- APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date IssuedThis Permit Expires 1 Year From Date Issued <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 /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS �jI �f � � the wv .t CITY/TOWN <br /> Owner' s Name Phone <br /> Address . City � .•� . <br /> Contractor' s Nam es �~"^`�" � License# <br /> 7anrThone Ay —76 7 -� <br /> C <br /> IS CERTIFICATE OF WORKMAN'S COh NSATION INSURAINCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION p _ WELL ABANDONMENT ❑ OTHER <br /> PUMP INSTALLATION Eta PUMP REPAIR❑ PUMP REPLACEMENT ❑ <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 /> Domestid/public Driven - Gauge of Casing <br /> cIrrigation 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 Pump 'T�.� .� ` —T— —. H,.P.._.._ --- <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP RE: &State Work Done � 4 <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 e <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 GROUT INSPECT ON ERI-OR-JO GROUTING AND A FINAL INSPECTION. <br /> SIGNEDITLE: P DATE: ! A; <br /> W LOT L N ON REVERSE SIDE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> " <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: Z. <br /> PHASE II GROUT INSPECTIONPH E I.IIIFINAL INSPECTION <br /> INSPECTION BY DATE .INSPECTION DATE <br /> x_1426 Rev. ]2-77 1 /78 2M <br />