Laserfiche WebLink
SAN JOAQUI;N LOCAL HEALTH DISTRICT <br />--FOR- OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.z,gr-1,1o7 <br /> k Telephone: (209) 466-.6781 <br /> APPLICATION' FOR WELL: CONSTRUCTION OR PUMP PERMIT Date Issued -3- S" <br /> This Permit Ex fres 1 Year From Date' Issued , <br /> � <br /> Compl ete In Triplicate <br /> Application is hereby made to the San Joaquin Local Health District 1. <br /> 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. 1v 2fa f S <br /> EXACT STREET ADDRESS/1-1. f CITY/TOWN -� ,, r_ <br /> V-Z° <br /> Owner's Name ' Phone <br /> Address aj.CA <br /> IF, City .� <br /> Contractor' s Name License� 1/� Phone - :Z <br /> IS CERTIFICATE OF WORKMAN'S COIMPENSATIO"1 INSURANCE ON FILE WITH SJLHD? YES I40 <br /> TYPE OF WORK (Check) : NEW WELLDEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLOFfINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTICI'TAN SEWER LINES . PIT PRIVY - - -� <br /> SEWAGE ;DISPO AL FIELD "DO <br /> CESSPOOL/SEEPAGE PIT OTH,Ef�=— <br /> PROPERTY LIN&��.fi'RIVATE O�ESTIC WELL_5 PUBLIC DOMESTIC WELL , <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial , ' Cable Tool Dia. of Well Excavation 0 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> _Irrigation Gravel Pack Depth of Grout Sea �-- <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information Lie <br /> Geophysical Surface Seal Instal ed b <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: . ❑ State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Proce ure <br /> 'I <br /> I hereby certify that I have 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 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 G <br /> not employ any .person in such manner as to become subject to Workman's Compensation <br /> laws of California." I <br /> I WILL CALL FOR A GROUT I PE TION IO.R TO GROUTING AND A FINAL INSPECTION. I <br /> SIGNED TITLE: DATE: <br /> PRAW PLOT PL ON REVER E <br /> SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE 3 7 <br /> APPLICATION.,ACCEPTED BY . <br /> ADDITIONAL COMMENTS. <br /> PHASE II GROUT INSPECTION- ` - ` PHASE --III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE_ <br /> 17 2M <br /> P11 I A n f Il_.. ,rl <br />