Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT t <br /> ..�lt.. CE USE: s/ 1601 E. Hazelton Ave. , Stockton, CA 95205 Per'mi t No. 7,9- <br /> Telephone.: <br /> 9_Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT 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 S ecu- CITY/TOWN <br /> Owner's Name '� ,,f a+, Phone &?. Q Ea Z, <br /> Address 1 <br /> Contractor's Name &f � � <br /> . z License#;z 7 Phone <br /> IS CERTIFICATE -OF WORKMAN'S COMPENSATION INSUR 1.CE ON FILE WITH-SJLHD? YES �— <br /> TYPE OF WORK (Check) : NEW WELL C1 DEEPEN CI RECONDITION [] DESTRUCTION[) <br /> WELL CHLORINATION 0 WELL ABANDONMENT ® OTHER 0 � <br /> PUMP INSTALLATION 0 PUMP REPAIRFa-- PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY `C <br /> SEWAGE DISPOSAL FIELD CESSP OL/SEEPAGE PIT OTHER �Y <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL T PUBLIC DUESTIC WELL <br /> INTENDED USE TYPE OF .WELL.. - CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of'Well Excavation <br /> Domestic/private Drilled �, -'Dia. of "W64 Casing <br /> Domestic/public Driven Gauge' of�Casing �! <br /> Irrigation Gravel Pack _ "`,Depth of Grout Sea <br /> Cathodic Protection Rotary Type•of,Grout <br /> Disposal Other Other Information r. <br /> Geophysical Surface Seal Inst- e <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP-�RE-PATR `:.r:r4 r. ._ _ t - T <br /> ❑State.Work Done __ _ <br /> DESTRUCTI��1ifi`0 W� Wel l Diameter Approximate Depth ~ <br /> Describe Materlial and Proce ure <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 FORA GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> aIGNED - TITLE: -. DATE: . S� T <br /> (DRAFFLOT PEAN ON REV SE SIDE <br />'HASE I R DEPARTMENT SE ONLY <br />�PPLICATION ACCEPTED BY DATE y Z 8 <br /> LDDITIONAL COMMENTS: . ZZZL� <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPECTION <br /> NSPECTION BY DATE ' �., INSPECTION BY DATE 3- <br />;H 14 26 Rev. .9/7 -- 9/78 2M <br />