Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT Permit No.=- - <br /> APPLICATION <br /> EOR FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205Telephone (209) 466w6781 Date IssueFOR WELL CONSTRUCTION OR PUMP PERMIT <br /> (Oompl.ete In Triplicate) + <br /> Application is hereby made to the San Joaquin Local i�cationealth District <br /> made infor <br /> compliancetwithnSanuct <br /> and/or install the work herein described. This application <br /> Joaquin County Ordinance No. 1862 and the Rules and* Regula't;ons of the San Joaquin Local Health , <br /> District. . <br /> CITY/TOWN /. <br /> EXACT -STREET ADDRESS D �. Phone G <br /> Owner's Name <br /> Address -- <br /> Contractor's Name ho V <br /> License# Phone <br /> IS CERTIFICATE OF Wa4MAN,SICOMPENSATION INSURA^!CE ON FILE WITH'SJLHD? YES 0 <br /> �,/ DESTRUCTION[� <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN L► RECONDITION❑ <br /> a <br /> � ABANDONMENT [- <br /> PUMP MWELL� IINSTALLATION CPUMP REPAIR❑-- .MP REPLA-3 OTHERCEMENT ENT El <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES IQd �- . PIT PRIVY <br /> SEWAGE DIS P SAL IELDCESSPODLJSEEPAGE <br /> IT OTICRWE�� <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLiC DAMES <br /> kCONSTRUCTION SPECIFICATIONS <br /> INTENDED USE ' TYPE OF -WELL <br /> Industria �Cabl-e_Tool. _ � _Dta.-of-We1�" Excavation <br /> Drilled Dia.. of Well Casing <br /> Domestic/private - <br /> Domestic/public Driven " Gadge of, ,Cas,ing #� <br /> , ._ 4G�^.avel_Pack" Depth-of` Grout Sea�-- <br /> Irrigation <br /> Cathodic Protection ` Rotary Type of Grout <br /> is Surface l; Other Other Information <br /> k _---Geophysical ` t1 Surface Seal insta ed <br /> PUMP INSTALLATION: Contractor H. . <br /> Type of Pump <br /> PUMP REPLACEMENT: ]State Work Done <br /> r� PUMP REPAIR: O State Work Done <br /> ; DESTRUCTION OF WELL: Well Diameter f. Approximate Depth <br /> Describe Mate ;-la an 3 Proce ure ". <br /> I 'hereby certify that I have prepared this application and that the-work will be done in accorda <br /> with San Joaquin. County Ordinances , State Laws , and Rules and Regulations of the San Joaquin -Loc <br /> Health. District. Home owner or licensed agent' s signature certifies the following: <br /> " <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 CAFOR A fflOUT INSP TION PRIOR TO GROUTING AND FIN INS PE91 ION. <br /> SIGNED TITLE: DATE:- <br /> D p L ON REV E SI E <br /> IU <br /> R DEP TMEN USE ONLY <br /> PHASE I 4 DATE 7 <br /> APPLICATION ACCEPTED BY '7�;O.J <br /> ADDITIONAL COMMENTS: 7 PHASE II GROUT INSPEON PHASE III FINAL INSPECTION <br /> CTI <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> - 9/.78 2 <br /> EH 14 26 Rev. 9/78 - <br />