Laserfiche WebLink
5AN JUAQUIN LUGAL MtALIM UIJIUL I <br /> FOR FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> I Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issue <br /> This Permit ` x ires I Year From Date Issued <br /> Complete In Triplicate �Dp'7-- ado <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 /> .'oapujn County Crdinance N0. , 1862_and ,the Rules and Regulations of the San Joaquin Local Health <br /> District. 1lo`43D:. <br /> EXACT STREET AD CITY/TOWN <br /> Owner's Name Phone <br /> Addressii, City <br /> Contractor's Name License Phone <br /> IS CERTIFICATE OFWORKMAN'S CQMPENSATIORN'INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITIONS' DESTRUCTION❑ ra <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ aQ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT ❑ " <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSP00L/SEEPAGE PIT OTHER <br /> PROPERTY L'I.NE -. 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 Dril-led 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 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: ❑State Work Done <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 WIL CALL OR A GROUT IN PECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: +k r— DATE: 15 <br /> AW PLOT PL N ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> AP �r- <br /> PLICATION ACCEPTED 8Y DATE <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSP CTION <br /> INSPECTION BY DATE INSPECTION BY c DATE? <br /> EH 1426 Rev. 12-77--- .. / G``�� 1 /78.'-' 2M <br />