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`{ 7 SAN JOAQUIN LOCAL HEALTH DISTRICT - <br /> FFICE USE: V, 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.,,f,/ 7 <br /> Telephone: (209)466-6781 <br /> APPLICATION FOR TELL CONSTRUCTION OR PUMP PERMIT Date Issued —3-2 <br /> This Permit Ex ires' l 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 /> Ucaqui n County Ordinance ado. 1862 and the. Rules and Regulations of the San Joaquin Local Health <br /> Cistr�ct. g <br /> EXACT STREET ADDRESS I� o �c �0iy CITY/TOWN ! ' <br /> Owner' s Name <fZ,* R 19 Al c :5-- 45u G/C Phone Al, <br /> Address �, y _ City <br /> lContractor' s Name_�/� - Licen�# 3 S7tS Phone <br /> j <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO"1 WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION Q DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER❑ <br /> PUMP INSTALLATION PUMP� REPAIR❑ PUMP REPLACEMENT <br /> ( DISTANCE TO NEAREST: SEPTIC TANK //Of SEWER LINA S PIT .PRIVY Q <br /> SEWAGE DISPOSAL FIELD //D ESSPOOL/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 /> Y _Domestic/private Drilled Dia. of Well Casing 75 <br /> Domestic/public Driven - Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor_ Al <br /> �.T <br /> Type of Pump- H.P. <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> f <br /> I hereby certify that I have prepared this application and that the work will be done in.-accordancc <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 FOR A GROUT SPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: <br /> �_ (DRVPLOT _PL_VN ON REVERSE SIDE <br /> FOR DEP RTMENT USE ONLY <br /> PHASE I <br />,APPLICATION ACCEPTED BY 41 DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECT ON , PHASE T NAL IASPECTION <br /> ,INSPECTION BY DATINSPECTION BY DATE /Z'2d <br /> Ik cle <br /> EH 1426 Rev. 12•-77 1 /78,,. .2M <br />