Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F ICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No."_g7$_ <br /> Telephone: (209) 466=6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT 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. / <br /> EXACT STREET ADDRESS �yC 139 /�a�L�bym `1�0/ CITY/TOWN 06 <br /> Owner's Name C Pa ,► — ' Phone <br /> Address / Z8 6 City ale, - <br /> Contractor's Name & License# Phone <br /> IS CERTIFICATE OF WORKt1AN'S CO" EN ATION INSURA^ICE ON FILE WITH SJLHD? YES X NO <br /> TYPE OF WORK (Check) : NEW WELL C) DEEPEN ❑ RECONDITION Q DESTRUCTION F1 <br /> WELL CHLORINATION 0 WELL ABANDONMENT O OTHER 0 -� <br /> PUMP INSTALLATION I PUMP REPAIR O PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC D MESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation C <br /> Domestic/private Drilled Dia. of Well Casing <br /> >< Domestic/public Driven Gauge of Casing <br /> X Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Insta , ed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump �T � ,jr H.P. eo ^too <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP Bim: ®State Work Done 11�um 7'7r/�irir A/au) t,,�y</ <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 FOR A GROUT INSPEC I.OR 0 G UTING AND A FINAL INSPECTION. <br /> SIGNED ITLE: DATE: N <br /> L PL ON REVERSE IDE <br /> PHASE I / DEP RTMEN USE ONLY <br /> APPLICATION ACCEPTED BY DAT <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY CDATE 4 27- 9S <br /> EH 14 26 Rev. 9174' 9/78 2M <br />