Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton -Ave. , Stockton, CA 95205 Permit No. - r <br /> Telephone: (209) 466-•6781 <br /> �z APPLICATION FOR "WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued <br /> This Permit Expires 1 Year From Date Issued <br /> Complete In Triplicate i <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 j <br /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS Ar7.i'Z r.�►. L� . }�. z 17� , CITY/TOWN <br /> Owners Name re Na?` A40 sy- o „ . Phone <br /> Address rZ 2 7"o Ste; City_ :hrA-A <br /> Contractor's Name 1tl ; �rcTL i c e n s e AoYJ`o Phone OSX - 1-7``/ <br /> IS CERTIFICATE OF WORKMAN'S COr"PENSATIO�! INSURANCE ON FILE WITH SJLHD? YES--,!!C— NO <br /> TYPE OF WORK (Check) : NEW WELL CI DEEPEN 0 RECONDITION ❑ . DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER n ) <br /> PUMP INSTALLATION PUMP REPAIRED PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY v <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> y PROPERTY LINE -, PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> � i <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> s Industrial Cable Tool Dia. of Well Excavation <br /> _Domestic/private Drilled Dia. of Well Casing <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 Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor Lc� ►G <br /> Type of Pump--_ ,r rT- H.P. / <br /> PUMP, REPLACEMENT: [] State Work Done _,... ,_..._. <br /> PUMP REPAIR: Q State Work Done <br /> DESTRUCTION OF WELL: Well Diameter S Approximate Depth <br /> Describe Materia 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 r <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 ,. TITLE: s DATE: 2 <br /> DR W PLOT PL N ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I i <br /> APPLICATION ACCEPTED BY DATE__�;- '7� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III F NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY a44DATE / <br /> t <br />