Laserfiche WebLink
1 SAN JOAQUIN LOCAL -HEALTH DISTRICT <br /> OFFICEFOR USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. /��/ <br /> Telephone:` (209) 466-6781 Date Issued 2 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit Expires 1 Year From Date Issued <br /> Complete In Triplicate <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 />,'oanuin County° Ordinance Nlo-- 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> t,2 elY <br /> EXACT STREET ADDRESS CITY/TOWN,��� <br /> Owner's Name Phone <br /> Address �!i [� City <br /> Contractor's Name --Licens � � Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION }Ir3SURA'ICE SON FILE WITH SJLHD? YES NO <br />' TYPE OF WORK (Check) : NEW WELL�`� DEEPEN ElRECONDITION Q DESTRUCTION <br /> WELL CHLORINATION E3 WELL ABANDONMENT Q OTHER(. <br /> E <br /> PUMP INSTALLATION M— PUMP REPAIR❑ PUMP REPLACEMENT [I <br />' DISTANCE TO NEAREST: SEPTIC TANK /Z_&!4SEWER LINES PIT PRIVY V <br /> SEWAGE DISPOSAL FIELD /,�"(� CESSPOOL/SEEPAGE PIT OTHER V <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 e� <br /> omestic/private Drilled Dia. of Well Casing <br /> iomestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea l <br /> Cathodic Protection rotary Type of Grout <br /> Disposals Other Other Information <br /> c Geophysical` ----� Surface Seal Instal ed b <br /> 'PUMP INSTALLATION:, Contractor <br /> Type of Pump �.� H. . <br /> [PUMP REPLACEMENT: State WorkDone <br /> ;PUMP REPAIR: QState Work Do_ne , - y <br /> iDESTRUCTIONaOF 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 in accordant <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 subject to Workman's Compensation <br /> laws of California. " <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED = „1� �LONR <br /> : DATE: <br /> DRAW PLOT �LNVERSESIDE <br /> FOR DRTMENT USE ONLY <br /> EP <br /> PHASE I <br /> APPLICATION ACCEPTED' BY --.^,. DATE <br /> 'ADDITIONAL COMMENTS: .. <br /> PHASE I ,GROUT INSPECTION=� PHASE III NAL INSPECTION <br /> :INSPECTION BY E '`. `� NINSPEC ION4BY DATE_V-_ <br /> i wM <br /> :. $ 2 <br />