Laserfiche WebLink
a - <br /> 1/ t SAN JOAQUIN';LOCAL,eHEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton :Ave. , ,Stockton, CA 95205 Permit No.7sr-/.�_ <br /> �1 Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Ex ires.,l 'Year From Date';Issued <br /> Complete .In Triplicate) ..' <br /> Application is hereby made to the San Joaquin Local Health Distr-ict .for a permit-to construct <br /> '; and/or install thefwork herein described. This application is made in- compliance with San <br /> ' ,oaquin County-erdInance-,�,o .4, 1862 .and the Rules and Regulations. of .the San Joaquin ,.Local Health <br /> . Dist.rict. � - <br /> ` EXACT STREET ADDRLSS r'.r:2- 3 !2 3 V 1 ^ ` 7iLe-� - CITY/TOWN Z, W <br /> Owne'r's Name /�j, VA Al _f o,y_f' Phone f -' 5�- <br /> �. <br /> Address f' city <br /> Contractor's Name License# Phone` <br /> IS CERTIFICATE OF WORKMAN'S ,COMPENSATIO"i INSURANCE ON -FILE 'WI'TH•SJLHD? YES NO <br /> ;TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION ❑-"f! DESTRUCTION❑- <br /> WELL CHLORINATION WELL ABANDONMENT C-1 OTHER ❑ <br /> PUMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY -k <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 /> Domestic/public 'Driven - Gauge of Casing <br /> Irrigation 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 OJAIIVfy { <br /> Type, 'of Pump___P M.P. <br /> PUMP REPLACEMENT: []State Work Done_ T Sk <br /> PUMP REPAIR: ❑State ,Work Done <br /> A <br /> DESTRUCTION OF WELL: Well -Diameter _ Approximate. Depth- <br /> Describe ftte—rial and Procedure <br /> 1I hereby certify that I haveprepared this application and t at 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 ownertor 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 Compe sation <br /> laws of California." t. ev -iyrz <br /> , I WILL CALV FOR GROUT JNSPECTION PRIOR TO GROUTING. AND A FINAL INSPEC IOT N. <br /> SIGNED 1' TITL-E:t DATE�� 7 �dr <br /> DRAW PLOT PLAN ON REVE E SIDE <br /> R DEP RTMENT USE ONLY <br /> ,PHASE I � <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS <br /> PHASE II GROUT INSPECTION PHASE III F NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY6 , .DATE O ��'f <br />