Laserfiche WebLink
SAN JOAQUIN l,-DCAL HEAL°fH U151'R1Cl <br /> QB OFFICE USE: 1 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. � <br /> Telephone (209) 466-6781 <br /> APPLICATION FOR WELL 'CONSTRUCTION OR PUMP PERMIT Date Issued 7 <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 fora permit to construct <br /> and/or install the work herein described. This,-application is made in compliance with San <br /> ,oaauin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin, Local Health <br /> 'District. <br /> EXACT ,STREET ADDRESS CITY TOWN v� TTJ•�' <br /> Owner's Name_ # ,,� L ; <br /> �vo r� . S7`ftcec?`c a ' - Phone Ers' - <br /> Address . ' <br /> C 7 ty S 7� <br /> Contractor's NameLicense# jr3Pdr Phone 2S <br /> - x <br /> S-, <br /> IS CERTIFICATE OF WORKMAN'S CO.MPENSATIO"! INSURANCE N FILE WITH SJLHD? YES NO <br /> TYPE OF -WORK (Check) : NEW WELL( DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION Q WELL ABANDONMENT ❑ OTHER❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT Q <br /> DISTANCE TO NEAREST: SEPTIC TANK 7 SEWER LINES-7S PIT PRIVY <br /> SEWAGEIDISPOSAL, FIELD '' CESSPOOL/SEEPbGE PIT /67 OTHER <br /> • PROPERTY LINE. PRIVATE DOMESTIC WELL �n _ PUBLIC DOMESTIC WELL <br />'k INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation /49 <br /> tfBDmestic/private Drilled Dia. of Well Casing <br /> -Domestic/public Driven Gauge of Casing ?VC, C.! s O <br /> Irrigation Gravel Pack Depth of Grout Seal 'a <br /> Cathodic Protection c_-Rotary Type of Grout r -- <br /> Disposal Other Other information <br /> Geophysical Surface Seal Installed by: 6m .,_ <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <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 CA L FOR A_ GROUT- INSPECTION PRIOR TO -GROUTING AND a FINAL INSPECTION. <br /> SIGNED TITLE: .c DATE: �.117 <br /> (DRAW PLOT PL N ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ,. <br /> APPLICATION ACCEPTED BY ZM� DATE X '7 <br /> ADDITIONAL COMMENTS:,_ - . -_ ­_ - <br /> PHASE II GROUT INSPECTI PHASE III FINAL INSPECTION <br /> INSPECTION BY (J DATE �Y INSP5CTION BY DATE <br /> FN l d`�f, [lntr 1 7_77 Z' 1 7 0 _ 7M <br />