Laserfiche WebLink
"N JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 '%w Hazelton Ave. , Stockton, CA %.,205 Permit No. �/ 7 <br /> Telephone: (209) 466-6781 S=�� <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. <br /> EXACT STREET ADDRESS %l35�7� Pc/ �i.,,N,g� .El' CITY/TOWN ; -tom <br /> —� <br /> Owner's Name ./�s;..Qti� s��ti�, Phone <br /> Address f�y�� Gtr �iy.��. �v Cityi,� , <br /> Contractor' s Name Li cense f2 72 )c Phonei:s F <br /> IS CERTIFICATE OF WORKHAN'S CO"PENSATION INSURANCE ON FILE WITH SJLHD? YES ;�� NO - <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION p WELL ABANDONMENT O OTHER 0 <br /> PUMP INSTALLATION E] PUMP REPAIR O PUMP REPLACEMENT.Er <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY F <br /> SEWAGE DISPOSAL FIELD CES�OL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> =Domestic/private Drilled Dia. of Well Casing e5_'r <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Informatioon <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: tate Work Done`,. <br /> PUMP REPAIR: ❑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 accordam <br /> Nith San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Loca <br /> iealth 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 .INSPECTIO PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED "4_ TITLE:p 6 DATE: !,: i <br /> DR W PLUT PLAN ON REVERSE SIDE) <br /> FOR DEP RTMENT USE ONLY <br /> 'HASE I <br /> APPLICATION ACCEPTED BY DATE_-��1_ <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br />