Laserfiche WebLink
_ 4 -SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR FFICE USE: 1601 E. Hazelton.Ave Stockton, CA 95205 Permit No.241--.44". <br /> Telephone: (209)466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued g-;u 7.� <br /> This Permit Ex ires 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 /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health. <br /> District. .� <br /> EXACT STREET ADDRESS CITY/TOWN r <br /> Owner's Dame PhoneICA- <br /> AddressCity - <br /> Contractor' s Name License Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO"! INS <br /> IPA <br /> ON FILE WITH SJLHD? YES NO ' <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN Q RECONDITION ❑ DESTRUCTION <br /> WELL CHLORINATION ❑ WELL ABANDONMENT Q OTHER CJ <br /> PUMP INSTALLATION 0 PUMP REPAIR❑ PUMP REPLACEMENT Q A <br /> DISTANCE TO NEAREST: SEPTIC TANKS SEWER LINES�_ PIT PRIVY <br /> SEWAGE DISPOSAL FIELD .— CESSPOOL/SEEPAGE PIT --- OTHER <br /> PROPERTY LINPt4PRIVATE DOMESTIC WELL ' PUBLIC DOMESTIC WELL `— <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool' Dia. of Well Excavation�2 f �. <br /> Domestic/private Drilled Dia. of Well Casing_ 4 f� <br /> Domestic/public Driven Gauge of Casing_ RV <br /> Irrigation _Gravel Pack Depth of Grout Sea <br /> Cathodic Protection y_Rotary Type of Grout <br /> Disposal Other Other Information p-•- r <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H• <br /> PUMP REPLACEMENT: ❑State Work Done <br /> 4 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 Loca. <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 CA FOR A GROUTAINSRECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: , <br /> (DRAW PL T L N ON REVER IDE <br /> FR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED B DATE B <br /> ADDITIONAL COMMENTS: f <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY� DATE INSPECTION BY DATE &6/7 <br /> AA1` -- - J "� JJ U !J 1 1 2M , <br />