Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued ///3-.:� <br /> This Permit Expires 1 Year From Date Issued <br /> Complete In Triplicate <br /> Application is hereby made to the San Joaquin LocaltHealth District for a permit to construct <br /> and/or install the work herein described. ' This application is made in compliance with San <br /> Joaquin CountyOrdinance No. 1862 aqd the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS � � _f r QU � ,� PL CITY/TOWN_ <br /> Owner' s Name -,- , I, Phone <br /> Address e "` q4p.� City <br /> Contractor's Name M. L►tj L i cense# Phone <br /> IS CERTIFICATE OF WORKtIAN'S C0111PENSATIO'N INSURANCE ON FILO WITH SJLHD? YES v NO <br /> TYPE OF WORK (Check) : NEW WELLURO' DEEPEN ❑ RECONDITION C3 DESTRUCTION <br /> WELL CHLORINATION ® WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION [J PUMP REPAIR❑ PUMP REPLACEMENT [� <br /> DISTANCE TO NEAREST: SEPTIC TANK/ yi _ 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 Cable Tool Dia. of Well Excavation <br /> sDomestjc . r'iv.ate Drilled Dia. of Well Casing <br /> Domestic/public — —"" Driven Gauge of Casing /p g1,i- <br /> Irrigation Gravel Pack Depth of Grout Seal - &0- <br /> Cathodic Protection _Rotary Type of Grout C11N m7-- - - <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by:,4,Aq 6,eoxS 'RUMP.*INSTALLATION: Contractor A A;� P��PA M 1P <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: Q State Work Done <br /> PUMP REPAIR: Q 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 WILL CALL,"R GROUT I EC ION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED �r�,/ TITLE: rr �„� <br /> DATE:- <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT, USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY AIZ DATE <br /> ADDITIONAL COMMS TS : <br /> PH E II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br />.EH 1426 Rev. 12777 - -- ' V <br /> 1 'ST� 2M <br />