Laserfiche WebLink
. SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. '"2 9_ 7 i d <br /> Telephone: (209) .466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued_[o <br /> t <br /> (,Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct SNI <br /> and/or install the,work herein described. This application is made incompliance with San <br /> Joaquin County Ordinance No. 1862 and the Rules -and- Regulations of the San Joaquin Local Health <br /> District. jS3C <br /> 4 <br /> EXACT STREET ADDRESS S S CITY/TOWN <br /> Owner's Name x e Phone_ !t-!2 15t_ ; <br /> Address - 10"E } City ... :. <br /> Contractor's Name License Phone,&, --2 ?/a <br />.YS' CERTIFICATE. OF WDRKIMAfd'S COMPENSATION INSURA^!CE ON -FILE WITH SJLHD? YES NO <br /> fiYPE OF WORK (Check) : NEW WELL DEEPEN Q RECONDIT.IQN,fo DESTRUCTION ElS <br />�t WELL CHLOINATION..Q WELL. ABANDONMENT Q OTHER 0 - r <br /> PUMP INSTALLATION Q.-_:P_UMP REPAIR❑ RUMP REPLACEMENT <br /> As— <br /> DISTANCE TO NEAREST: SEPTIC TANKsl�� SEWER LINE PIT,.PRIVY -� ' _ <br /> SEWAGE DISPOSAL, FIEL-D�� CESrSPOL/ P ,GE PIT t-.�. OTHER <br /> _ PROPERTY €.IN&MQ PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL - - <br /> INTENDED USE TYPE OF WELL CONSTRUCTION. SPECIFICATIONS <br /> to 4 i <br /> Industr7al Cable Tool Dia. of Well Excavat!on <br /> _Domes tic/private Drilled ' : ` �` Dia. of Well Casing , <br /> Domestic/public 14 Driven Gauge of Casing s <br /> .46,0 elle <br />_ Irrigation t�Gravel Pack. Depth,' Grout Sea I <br /> Cathodic Protection - _Rotar_y Type of Grout <br /> ` _ _ Disposal Other. Other Information <br /> Geophysical Surface Seal Installed by.: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. w <br /> 9 <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP .-REPAIR: Q State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate-Depth <br /> Describe Material and Proce3_ure <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,.Rul6s .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 subject to -Workman's Compensation -- <br /> f laws of California'. ". €`. <br />'I WILL CALL FORA 009 I I.ON P `IOR TO GROUTING AND A`FINAL INSPECTION. <br />`S.IGNED - TITLE: 4&gvt DATE: <br /> } ' PL L N ON REVERSQ SIDE) . <br /> OR DEPARTMENT USE ONLY <br />,�PHASE I � .. (S _ _ <br />�kPPLICATION'"ACCEPTED BY _ �f DATE ( 7 7 <br /> ADDITIONALCOMMENTS: <br /> r � PHASE II GROUT INSPECTION <br /> PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE t INSPECT-IDN 8-Y DATE <br /> � 7 <br /> EH 14 26 Rev. 9/78 _ 9/78 .. .R 2M <br />