Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Perm3•t, No.EOR <br /> Telephone: '(209) 466=6781 <br /> a`+ Date Issued <br /> APPLICATION FOR WELL CONSTRUCTION 09'PUMP PERMIT <br /> (Complete In Tri pl i'cate). �� 3 <br /> Application is hereby made tothe San Joaquin Local Health District fora- permit.to construct <br /> and/or install the work herein'F,described. This applicat-ion .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 DRESS � 'd Q y <br /> CITY/TOWN <br /> Owner's Name G • -4,1-2 - Phone ? 1 Z <br /> , <br /> 'Address City <br /> C3 <br /> ense <br /> c �42323_- Phone <br /> Contractor's Name Li <br /> � - - <br /> IS CERTIFICATE-OF WORKMAN'S --CO"iPFNSATIO" INSURANCE ON FILE WITH SJLHD? YES v O. <br /> } <br /> STYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION IR <br /> Q DEOTW. <br /> RUCTI NInn���-.—•-- <br /> WELL CHLORINATION Q WELL <br /> PUMP INSTALLATION 0 PUMP REPAIRCR PUMP REPLACEMENT C7 <br /> � j <br /> DISTANCE TO NEAREST: SEPTIC' TANK SEWER LINES_ ... PIT PRIVY OTHER G- <br /> SEWAGE;DISPOSTL FIELD CESSP L/SEEPAGE PIT / <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLR DYESTIC WE— LE <br /> INTENDED USE - TYPE OF WELL <br /> CONSTRUCTION SPECIFICATIONS - v <br /> Industrial Cable Tool Dia. .of Well Excavation <br /> Domestic/.private , Drilled Dia. of Well Casing } <br /> Domestic/public DrivenGauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protect ion Rotary 'Type of Grout <br /> E Disposal Other Other Information <br /> Geophysical Surface Seal InsLTTed b <br /> POMP -INSTALLATION: Contractor /� ' <br /> •-- Type of Pump *' H. <br /> PUMP REPLACEMENT: � N (]State Work Done t R <br /> `r PUMP REPAI-R-: RState Work Done <br /> ` .�.. ' <br /> ` DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materia - and Procedure I <br /> � I hereby certify that .1 havelprepared 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--Joaqu•in Local <br /> Health District-. Home owner (or licensed agent' s signature certifies the following: <br /> "I certify that i-n 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 R GROUT I . PECTION P IDR TO GROUTING AND 'A FINAL INSPECTION. <br /> TITLE:' DATE: <br /> SIGNED <br /> P ON REVERSE .S E <br /> OR DEPARTMENT USE ONLY <br /> I PHASE I' DATE - <br /> PPLICATION ACCEPTED, BY zz <br /> ! ADDITIONAL COMMENTS: f g <br /> PHASE IF GROAT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> M. <br /> rfa Id 9ff Rev_ 9178 <br />