Laserfiche WebLink
JOAQUIN LOCAL HEALTH DISTRICT <br />—FOR FFICE USE: 1601 ..;Hazelton Ave. , Stockton, CA g 15 Permit No.79-ke-/2 <br /> Tel ephor,e: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 8-7 <br /> (t,omplete. In Triplicate) ll <br /> Application is hereby made to the San Joaquin Local Health District for °a permit_to construct 1 <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 Rdl L� E �� T wN is e IQ1Z _ <br /> Owner's Name <br /> Ad <br /> Phone 7 <br /> Address citys .. <br /> Contract-or's Name AdUFA,5 License Phone s? <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD?. YES No' r <br /> TYPE OF WORK (Check) : NEW WELL C! DEEPEN RECONDITION ® DESTRUCTION[:J <br /> _ WELL CHLORINATION [3 WELL ABANDONMENT 0 OTHER 0 <br /> ► : PUMP INSTALLATION M PUMP REPAIR❑ PUMP REPLACEMENT Ca j <br /> DISTANCE TO NEAREST: SEPTIC-TANK�R2'4-_ SEWER LINE O.P'4 .PIT PRIVY <br /> SEWAGE DISPOSAL FIELD/o CESSP OL/SEEPAGE PIS OTHER — <br /> PROPERTY LINVAPRIVAT FIELD/op <br /> WELL SA—'-:L PUBLIC DOMESTIC WELL: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS,. <br /> Industrial [ Cable Tool Dia. of We 1 Excavation <br /> �. Domestic/private Drilled Dia. of Well Casingy&W <br /> bomestic/public Driven Gauge of Casing <br /> _Irrigation Gravel Pack Depth of Grout Seal 4V -�-- <br /> Cathodic Protection Rotary Type of Grout ' <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Install : <br />' PUMP. INSTALLATION: Contractor <br /> Type of Pump H.P. <br />' PUMP REPLACEMENT: ❑State Work Done <br /> SUMP REPAIR: ❑State Work Done <br />, )ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br />' [ hereby certify that I have prepared this application and that the -work will be done in accordanc <br /> with San Joaquin County Ordinances , State Laws, and Rules and Regulations of the- San Joaquin Local <br /> I, lealth 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 /> E laws of California. <br />' [ WILL CALL FOR A WUT,,?INSEMZON PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> iIGNED TITLE: DATE: <br /> azu <br /> D P L ON REVERS E <br /> RA, EP RT MEN USE ONLY <br /> 1HASE I <br /> MPLICA ION ACCEPTED B DATE <br /> i MITIONAL COMMENTS: <br /> !PHASE,.I GROUT INSPECTION PHASE III FINAL INSPECTION <br /> fiISPECTION BY DATE INSPECT E DATE 7 <br /> A 14 26 Rev. 9/7 � BY <br /> '�� <br />