Laserfiche WebLink
SAN JOAQUIN LOCAL HEALIH D1SIR1L1 <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.;y_iy 6 9 <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 /> _plication 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 /> 'oaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> istr�ct. <br /> EXACT STREET ADDRESS eL'�l L/ / <br /> -'T <br /> aner' s Name < <o u o T a.� e/ a Phone <br /> _,,(&&L �' ! / x'6'6-� 30 <br /> )rddress 1,1-/c/ / FWlea 7 Se City f/yq-,0/nx7y <br /> )ntractor's Name 41V jS c Licensee ,r Phone ?/s-3:CZS <br /> `PS CERTIFICATE OF WORKMAN'S COMPENSATIO.1 INSUR CE ON FILE WITH SJLHD? YES NO <br /> YPE OF WORK (Check) : NEW WELL 23— DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 0 OTHER <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> ,DISTANCE TO NEAREST: SEPTIC TANKS SEWER LINES `�Q� PIT PRIVY <br /> SEWAGE DISPOSAL FIELD' ; ' CESSPOOL/SEEPAGE PIS OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL � 1 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> _Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 0ALe- /Go \ <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 b etc <br /> -JMP INSTALLATION: Contractor \ <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑State Work Done <br /> JMP 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 accordant <br /> ith San Joaquin County Ordinances, State Laws , and Rules and Regulations of the San Joaquin Local <br /> �alth 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 /> T WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> 'IGNED TITLE: DATE: I,? JP <br /> (DRAW PLOT PLTN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> "4ASE I <br /> 1PLICATION ACCEPTED BY l'c_� DATE 131-29 <br /> ADDITIONAL COMMENTS:A? /S 7 gro ^ <br /> PHASE II GROUT INSPECTION PHA I F INSPECTION <br /> 1SPECTION BY DATE INSPECTION B DATE r Z/4 Z <br />