Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (20) 46,6-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Expires 1 Year From Date Issued <br /> Complete In Triplicate r�7_ F3w—Zn <br /> Application is hereby made to the San Joaquin Local Health District for 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. <br /> EXACT,STREET ADDRESS . At CITY/TOWN <br /> 0 64 <br /> Owner's Name Phone <br /> Address idaCity <br /> Contractor's Name License Phone Qy���y/�? <br /> IS CERTIFICATE OF WORKMAN'S CONiPENSATIO'! Iia RANlCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION p DESTRUCTION❑ <br /> WELL CHLO INATION 0 WELL ABANDONMENT 0 OTHER Q <br /> PUMP INSTALLATION 0 PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK<al SEWER LINESyo /f PIT PRIVY ---- X, <br /> SEWAGE DISPOSAL FIEL��I CESSPOOL/S PA E PIT OTHER tN <br /> PROPERTY LINet-4 PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL c— <br /> Ph <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ' <br /> Industrial Cable Tool Dia. of Well Excavation " <br /> Domestic/private Drilled Dia. of Well Casing r <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout CV-,",0"Au �c <br /> Disposal Other Other Information --, <br /> - --------- <br /> Geophysical Surface Seal Installed by: --- <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑State Work. Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done ire Ice <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San JoaqHealth 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 shal <br /> not employ any person in such manner as to become subject to Workman's Compensation <br /> laws of California. " <br /> I WILL CA FORA R CTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> S I G N E TITLE: L. ._. DATE: <br /> 77- <br /> PR-A W PLOT PLTN— ON REVE731 SIDE <br /> PHASE I <br /> FOR DEP RTM NT ONLY APPLICATION ACCEPTED BY gvl� -4 1 DATE / 8� <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE jii, u(uINSPECTION <br /> INSPECTION ,BY �M _ _ DATE '&Z, INSPECTION BY DATE J---21—,f2- <br /> EH, <br /> S=a/,fzEH. 1426 -Rev_, 12-77 1/7'8 2M <br />