Laserfiche WebLink
SAN JOAQUIN LUCAL HEAL-1H DISIKICI --- <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.7 -- 3,9 <br /> Telephone: (209) 4666781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued!�L-6. <br /> This Permit Ex ires .1 Year From Date Issued <br /> Complete I-n Triplicate) . // <br /> gg— jj <br /> Application is hereby made to the San Joaquin Local Health District for a permit to7constr.uct <br /> and/or install the- work herein described. This application is made in compliance with San <br /> ,canuin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> JiStriCt. <br /> EXACT STREET ADDRESS CITY/TOWN / <br /> Owner' s Name " Phone �r7 <br /> Address 4'/'��,E___. City <br /> Contractor' s Name IV License# Phone <br /> IS CERTIFICATE OF WORKMAN'S C0111PENSATIO f INSURA"MCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION o <br /> WELL CHLORINATION ❑ WELL ABANDONMENT p OTHER' <br /> PUMP INSTALLATION C' PUMP REPAIR❑ PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ": PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL l CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation v' <br /> Domestic/private Drilled - Dia. of Well Casing <br /> �-. Domestic/publ.ic - ` Dri-ven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of, Grout <br /> -Di-sposa-1 �. Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor N' 0�- <br /> Type of PumpH.P. <br /> PUMP REPLACEMENT: []State Work- Done <br /> PUMP REPAIR: ❑State Work Done 4. <br /> DESTRUCTION OF WELL: Well Diameter az-P �'�« + �"f'` �pproxi ateDept w <br /> Describe Materia an .- Procedure u,�.--�_ G;fT >.nf_Tr4L c& . <br /> r - <br /> I hereby certify that I have prepared this application andthat 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 <br /> not employ any person in such manner as to become sub.ject.- to,Workman.'s Compensation t <br /> laws of California. i <br /> I WILL CALLR_AQROUTPSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. ' <br /> SIGNEDX' TITLE: DATE: - <br /> (DRAW PLOT PUN ON REVERSE SI <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I w <br /> APPLICATION ACCEPTED BY DATE 2:1 <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE IIL FINAL I SPE-C-T-IO�N <br /> INSPECTION BY DATE_ 1✓ ��� INSPECTION BY DATE <br /> � <br />