Laserfiche WebLink
SAN JOAQ�IIN -LOCAL HEALTH DISTRICT - <br /> FFICE USE: `- w 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. ,f - J37! <br /> ? <br /> / Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <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 /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. $1?s <br /> EXACT STREET ADDRESS SS f dZE / CITY/TOWN <br /> Owner's Name— /` n,t f -- Phone. z"4/1_K <br /> Address City <br /> Contractor' s Name License# Phone <br /> IS CERTIFICATE OF WORKtiAIVS COMPENSATION! I�dSURAN E ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL EM DEEPEN El - RECONDITION 0 DESTRUCTION� W <br /> WELL CHLO INATION Q WELL ABANDONMENT a OTHER 0 <br /> PUMP INSTALLATION CI PUMP REPAIR❑ PUMP REPLACEMENT ❑ Q <br /> DISTANCE TO NEAREST: SEPTIC TAN # SEWER LINES ��� PIT PRIVY <br /> SEWAGE DISPOSAL FIEL[5p r j CESSPOOL/SEEPAPE PIT,Sa f OTHER --- <br /> PROPERTY LINE/Q. PRIVATE DOMESTIC WELL �-f PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation�a <br /> _,Domestic/private Drilled Dia. of Well Casing rf <br /> Domestic/public Driven Gauge of Casing <br /> iW_Irrigation _Gravel Pack Depth of Grout Seal f <br /> Cathodic ProtectionRotary Type of Grout <br /> 'Other Other Other Information <br /> Geophysical Surface Seal Installed by: , � <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: (7 State Work Done <br /> PUMP REPAIR: Q State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Proce 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 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 j <br /> laws of California. " <br /> I WILL C L FOR 0GRI P56ION PRIOR TO GROUTING AND A FINAL INSPECTION. I+, <br /> SIGNED TITLE: DATE:/& <br /> (DRAW PLOT P/LAN ON REVERSE 01DEL <br /> FOR D ARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY(7;kt("? f DATE 7� <br /> ADDITIONAL COMMENTS : <br /> PHASE 1I GROUT INSPECTION PHASE All FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY r DATE ��� <br /> �'r� <br /> EH 146 Rev: 1/78 2M 12-77 - - <br />