Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR FFICE USE: `1601 E. izeltoa Ave.., Stockton, CA 91 i Permit No. 79-ziff9 <br /> .Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued $-IQ-'7 9 _ <br /> This Permit Expires 1 Year From Date Issued <br /> (Complete In Trip icate <br />,pplication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> nd/or install the work herein described. This application is made incompliance with San <br />'oanuin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> iistrict. <br />.XACT STREET ADDRESS •�/9l CITY/TOWN <br /> Wner' s Name Q �� - � Phone—Elf— <br /> iddress City <br />:ontractor's Nam Licensees Phone /o <br /> IS CERTIFICATE OF WORKMAN S COMPENSATION! INS RANCE ON FILE WITH SJLHD? YES JNO <br />_ <br /> YPE OF WORK (Check) : NEW WELL tZ DEEPEN p RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION (3 WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION PUMP REPAIR 0 PUMP REPLACEMENT ❑ S <br />•IISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cabe Tool Dia. of Well Excavation <br /> t-,-16mestic/private Drilled Dia. of Well Casing A <br /> Domestic/public Driven - Gauge of Casing <br /> Irrigation ', Gravel :Pack Depth of Grout Sea <br /> Cathodic Protection 4,, 'otary Type of Grout <br /> Disposal Other Other Informations <br /> Geophysical Surface Seal Ins talle y: <br />''UMP INSTALLATION: Contractor <br /> Type of' Pump H• <br />"UMP REPLACEMENT: []State -.Work Done <br />''UMP REPAIR: ❑Statg Work Done <br />)ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materiaan Procedure <br /> hereby certify that I have prepared this application and that the work will be done in accordance <br />.rith San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local <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 /> WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING. AND A FINAL INSPECTION. <br />;IGNEDTITLE:WDDATE: <br /> T L N ON REVE SE S E <br /> FOR 'DEP TMEN USE ONLY <br />'HASE I AA <br />�PPLICTTION ACCEPTED BY a� 2aY��a. .J DATE <br /> 1DDITIONAL COMMENTS. <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> NSPECTION BY � DATE INSPECTION BY .tt„DATEEE,/aD <br /> .- �� (P 1 /-7R 7M <br />