Laserfiche WebLink
E _._.._.._ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: I1601 E. Hazelton Ave.-, Stockton, CA 95205 Permit No. 77_ 6y a a . <br /> Telephone: (209) 466-6781 <br />• APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued ,s_ <br /> (Eomplete�In Triplicate) <br /> Application "i,s hereby made to the San Joaquin Local Health Distri <br /> fora permit- to construct V <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- Regula-tions of. the San .Joaquin Local 'Health <br /> District. <br /> EXACTSTREET ADDRESS Q Q CITY/TOWN <br /> r Owner's Name .._ <br /> Phone <br /> Address <br /> Cit <br /> Contractor's Name P License# 3 Phone ��� <br /> IS CERTIFICATE OF WORKMAN'S COVIPENSATION INSURANCE ON ~FILE WITH SJLHD? YES N0 � <br /> - <br /> TYPE I'OF:WORK"(Check) : 'NEWWLLCDEEPEN'❑ wRECONDITION � � - i <br /> [� �'DESTRU07ION[� <br /> WELL CHLORINATION ❑ WELL ABANDONME ❑ ' OTHER❑ <br /> ' PUMP INSTALLATION ❑ PUMP REPAIR[ , PUMP REPLACEMENT ❑ W . <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIV PRIVY } <br /> SEWAGE DISPOSAL FIELD CESSPOOL/.SEEPAGE IT OTHER <br /> PROPERTY LINE - PRIVATE DO ESTIC WELL, PUBLIC DOMESTIC,WELL <br /> INTENDED USE' « <br /> TYPE OF-WELL,_' `" CONSTRUCTION SPECIFICATIONS <br /> ndustrial <br /> Cable Tool D,ia: of Wel Excavation <br /> Domestic/pri.vateDrilled Dia. of We!'] Casing <br /> Domestic/public <br /> Driven Gauge of Casing <br /> �,�Irrigation Gravel Pack Depth,- of Grout Sea txti <br /> _____Cathodic ~Protection Rotary T <br /> i sposal y p e of arout. ._' <br /> eophysica] Other Other Information <br /> Surface Seal Insta ed <br /> PUMP - INSTALLATION: Contractor <br /> Type of Pump - <br /> PUMP REPLACEMENT: H.P. <br /> ❑State Work Done <br /> PUMA REpAIR:` tate Work Done �f R <br /> DESTRUCTION OFWELL Well Diameter �' 17 <br /> Describe Materia and Procedure Approximate-,Depth. <br /> I hereby certify that I have preparedapplicationT <br /> and that the work will be done in accordanc <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 ' <br /> ,any person in such manner as to become subject to Workman 's Compensation <br /> lawsrof California. �- <br /> I IL <br /> CALL -TOR A GROUT:rINSPECTION PRIOR TO_GROUTING,AND A FINAL INSPECTION, ` <br /> tA <br /> ED <br /> '� f TITLE: <br /> DR W.�PLOT}PL N ON REVERSE E DATE: <br /> t . n FO DE ARTME T USE ONLY <br /> APPN ACCEPTED BY <br /> COMMENTS: _ ` , x DATE <br /> ,,._, —S /// <br /> PHASE II GROUTINSPECTIONINSPECTION by DATE PHA I L INSPECTION <br /> EH 14 26 Rev. 9/78 INSPECTION PHM <br /> N DATE —Z eZ, , <br /> x,9/78 -2M s <br />