Laserfiche WebLink
. SAN JOAQUIN LOCAL HEALTH DISTRICT h <br /> FIFICE USE: 1601 E. Hazel tan Aver, Stockton, CA 95205 Permit No. / + <br /> FOE Q —/ <br /> Telephone: . (209) 466-6781 Date Issued <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT f <br /> l�. <br /> This Permit Expires 1 Year From Date Issued ; <br /> Complete In Tri pl`i Cate ' <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 ane comSanpJoaquenwith LocalaHealth <br /> Joaquin County Ordinance No.. 1862 and the Rules,-and Regulations of t <br /> Distr�ct. <br /> EXACT STREET ADDRESS CITY/TOWN <br /> 11 Phone <br /> Owner's Name ; <br /> City. <br /> Address - <br /> II Lic sed Phone, <br /> Contractors Name !� <br /> IS CERTIFICATE OF WORKl1AN S COMfENSATIO' I4aS <br /> iivamCE nq FIL WITFI SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ELL ABANDONMENT ® OTHER 0 <br /> :„_ pPUMP INSTALL�ATTONr�° . P;. REPAIR❑ PUMP REPLACEMENT <br /> DISTANCE TO NEARES1,.” SEPTIC TANK SE z PIT PRIVY , <br /> SEWAGE DIS SL FTEL_D /SEEPAGEPIT OTHER <br /> PROPERTY LINE -. PRIV` TJ C`WELL `- PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL> � . W. <br /> CONSTRUCTION SPECIFICATIONS <br /> r D7 a. of ,4Iel l Excavation <br /> Industrial Cable Toad � <br /> r' Di a. of Well Cas i ng <br /> �Bomesti c/pri vate - -I1ri l l.ed <br /> I Gauge of Casing_ / <br /> it Domestic/public Dri vr� �.� <br /> Irrigation � Grar ' Pack Depth- of Grout-Seal <br /> t I Cathodic Protection cam-Rotary Ty pe-�f�.Grout tl <br /> 0th Other Information <br /> �, Disposal Surface Seal Instal 1 ed b <br /> 1I Geophysical , { <br />� <br /> Contractor _ _PUMP �;INSTALLATION: T e of Pum _ H.P. <br /> YP p <br /> PUMP REPLACEMENT: State Work Done - <br /> PUMP 3REPAIR: QState Work Done "` % <br /> Approximate Depth <br /> I DESTRUCTION OF WELL: Well Diameter r- - <br /> Describe Materi al and Procedure r <br /> II hereby certify that I have prepared this application <br /> and that the work will be done in accordanc <br /> withilSan 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 fallowing: <br /> "Icertify 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 /> . . <.s.; <br /> laws of California." <br /> � T WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. a <br /> SIGNED TITLE: — —DATE: <br /> DR W PL T PL N ON REVERSE' SIDE -- ! <br /> ii FOR DEPARTMENT USE ONLY--' <br /> PHASE I DATE. G� <br /> IA�PLtiICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> J <br /> PHASE II GROUT INSPECTION <br /> �—��7m—Aqj: III IN INSPECTION <br /> INSPECTION BY <br /> DATE INSPECTION BY DATE S: <br /> ___ -fn '77 _- <br />