Laserfiche WebLink
v SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 96205 Permit <br /> Telephone: (209) 466-6781 <br /> -- APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued X 7 <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 /> loanuin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS 7r gui�` �?yCITY/TOWN <br /> Owner's Name ,�.�;./ ��, Phone <br /> Address Z 7 City r" <br /> Contractor's Name License Phone <br /> IS CERTIFICATE OF WORKt1AN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES ��''� N0�____ <br /> TYPE OF WORK (Check) : NEW WELL O DEEPEN O RECONDITION C DESTRUCTION <br /> WELL CHLORINATION 0 WELL ABANDONMENT O OTHER 0Ai <br /> PUMP INSTALLATION O PUMP REPAIR O PUMP REPLACEIME C] <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE D MESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> _ Industrial Cable Tool Dia. of We Excavation <br /> _ Domestic/private Drilled Dia. of Well Casing <br /> Domestic,/public Driven - Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Insta e b <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H. . <br /> PUMP REPLACEMENT: ❑St to Work Done <br /> PUMP REPAIR: tate Work Done <br /> DESTRUCTION OF WELL: Well Diameter �```''` oximate 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 INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED e, TITLE:( <br /> DATE: <br /> DR W PLOT PL ON REVER SIDE V -- <br /> R DEPARTMENT USE ONLY <br /> P '^SE I <br /> ICATION ACCEPTED BY DATE L7Zc�l <br /> AvuITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE /---s 2_ <br /> 2M <br /> EH 1426 Rev. 12-77 1 /7# <br />