Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: /1601 E. Hazelton Av.e. ,. Stockton, CA 95205 Permit .No. g , <br /> Telephone: (209) 466-6783. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued,--?r <br /> This Permit Expires I 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 Joaqu.in Local Health <br /> . 'District. <br /> EXACT STREET ADDRESS CITY/TOWN <br /> 61 <br /> Owner's Name Phone <br /> Address '� e //: '� <br /> Contractor' s Name License# a Phone . df�- <br /> IS CERTIFICATE OF WORKMAN'S CO3MPENSATIO1111 I'11SURAINCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELLW DEEPEN 0 RECONDITION ❑ DESTRUCTION[] <br /> WELL CHLORINATION C3 WELL ABANDONMENT © OTHER 0 <br /> PUMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT 1-4 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER t <br /> PROPERTY LINE -, PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well ExcavationIq, <br /> Domestic/private _ Drilled Dia. of Well Casing <br /> Domestic/public 7eDrivenGauge of Casing Q <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractorj'� i <br /> Type of Pump <br /> H.P. F <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF 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 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 <br /> laws of California. " <br /> I WILL CALL FORA ROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE:, <br /> DRAW PILOT PL N ON REVERSE SIDE <br /> FOR DEPARTMEN ONLY ' <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE �- Y <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE IIIJINAL INSPECTION <br /> INSPECTION BY DATE <br /> INSPECTION BY j DATF�-— <br />-H 1426 <br /> 1 1-70 A 1]7..i <br />