Laserfiche WebLink
x � SAN JOAQUIN: LOCAL-HEALTH DISTRICT <br /> OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. �B <br />�._._. Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit .Ex ires 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 descri berd. -,Th-is appl i cati o.n ' i s. Made. i n compliance with. San, <br />'oaQbin CountyOrdinance No. .1862 and the Rules and Regulations of the San-.'J_o.aquin Local Health <br /> District. <br /> EXACT STREET ADDRESS ' CITY/TOWN ► <br /> Jwner's Name Phone <br /> Address c City Aygo�. <br /> Contractor's Name " License#� Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPEN ATIO,'J INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF..WORK -(Chec.k) : NEW WELL M- =-DE-EPEN Q RECONDITION (D DESTRUCTION[j <br /> WELL CHLORINATION 0 WELL ABANDONMENT E3 OTHER ( <br /> PUMP INSTALLATION- R PUMP REPAIR[ _ PUMP REPLACEMENT E] <br />]ISTANCE TO NEAREST: SEPTIC TANK 60'-t- SEWER LINES 0-7-PIT PRIVY r <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER „ <br /> PROPERTY LIN LA� PRIVATE DOMESTIC WELL-162%y PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS T -C <br /> Industrial Cable Tool Dia. of Well Excavation l <br /> �— Domestic/private Drilled F Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal_ _ <br /> Cathodic Protection Rotary- -Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br />'SMP INSTALLATION: Contractor v <br /> .Type of Pump e'd re ,_.._.,- H.-P. <br />?UMP REPLACEMENT: []State Work Done <br />)UMP REPAIR: Q State Work Done <br />)ESTRUCTION OF WELL: Well Diameter Approximate -Depth <br /> Describe Material and Procedure <br />[ hereby certify. that I have prepared this application and that the work will be done in accordance" <br /> lith San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local F <br /> lealth District. Home owner or licensed agent's signature certifies"the fol'Towing: r <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 /> WILL CALL FOR A GROUT INSP CTION PRIOR TO GROUTING AND J FINAL INSPECTION. <br /> SIGNED TITLE: -,0,1� DATE: /z ` <br /> DR W PLOT PLAN- ON REVERSE SIDE <br /> FOR QEPARTMNT USE ONLY <br />'HASE I ' <br /> APPLICATION ACCEPTED BY ,DZd� DATE Z /� `7e <br /> iDDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> NSPECTION BY DATE INSPECTION BY DATEi > <br /> H 1426 Rev. 12-77 _ _ 1/78 2K'Y � <br />