Laserfiche WebLink
F. <br /> SAN JOAQUIN LOCAL HEALTH UlSlRi l <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.7g/617,3 <br /> Telephone: {209) 466-6781 <br /> APPLICATION FOR 'WELL CONSTRUCTION OR PUMP PERMIT Date Issued2Lay_) <br /> This Permit Expires I 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 /> ,'oaquin County Ordinance Nlo. . 1862 and the Rules and Regulations of the San Joaquin Local Health - <br /> rDistr�ct. <br /> EXACT STREET AQPRESS CITY/T01 <br /> Owner' s Name Phone <br /> Address'—,., <br /> i Contractor's . Name License#�� Phone Z <br /> t IS CERTIFICATE OF WORKMAN'S COMPENSATION INSUR !!CE .ON`,FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Chieck) : NEW- WELL DEEPEN ❑ RE.CONDITI6W DESTRUCTION❑ "`C� <br /> WCHELL ' LORINATION E] WELL-ABANDONMENT ED OTHER F <br /> PUMP__INSTALLATION [ UMP REPAIR❑ PUMP REPLACEMENT ❑ Q <br /> DISTANCE TO NEAREST: SEPTIC TANK Pe - EWER LINES, 'PIT PRIVY _ <br /> SEWAGE D.ISPOS FIELD C SE SPOOL/SEEPAGE'PIT,. ��HER <br /> PROPERTY 1-INA_)'RIVATE DOMESTIC WELL '�'"'T PUBLIC.OMESI`IC WELL e1 1 <br /> INTENDED USE TYPE-OF WELL CONSTRUCTION SPECIFI6`ATION5 <br /> Industrial Cable Tool Dia. of Well Excavation <br /> - D estic/private 11 ed Dia. of Well Casing <br /> Domestic/Public Driven Gauge of Casing <br /> Irrigationravel Pack Depth of Grout Seal 47-10 <br /> Cathodic Protection Rotary ,Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed b : <br /> PUMP INSTALLATION: ContractorWee �- . <br /> Type of Pump �Y H.P. <br />' PUMP' REPLACEMENT: [] State Work Done 3 <br /> PUMP REPAIR: ❑State, Work;Done <br /> DESTRUCTION OF WELL: Well Diameter t Approximate Depth <br /> De cribe Materia man Procedure <br /> I' I hereby certify that I h ve 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 Local1 <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 U INSPECTION PRIOR .TOyOROUTING AND A FI AL I SPECT ON. <br /> SIGNED TITLE: DATE: <br /> DR W PLOT PLTN ON REVE S SIDE <br /> ra, FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY of .. Z DATE // <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY ( ` DATE l`L `� INSPECTION BY DATE <br /> EH 1426 Rev,_ 12-77 x 1 79- 9M ti <br />