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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 TELL CONSTRUCTION OR PUMP PERMIT Date Issued -9- <br /> This Permit ,Exfires 1 Year From Date Issued <br /> Complete In .Triplicate <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct <br /> and/or install the work herein described. This application is made i.n' Compliance with-San <br /> ,oaQuin County Ordinance No. 1862 and the Rules and Regulations of the`San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS (f7 Z_ <br /> CITY/TOWNS I-04rl( / <br /> Owner's Name'' Phone <br /> Address967 <br /> y . c,ty s--/0 Cd �j <br /> Con tractar'-s'Name-- LA <br /> I-Cens-e#7tM 2Phone ` + <br /> IS CERTIFICATE .OF WORKMAN'S COMPENSATIOIN INSURAINCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION t <br /> ; WELL CHLORINATION ® DESTRUCTION <br /> � U WELL ABANDONMENT Q OTHER 0 <br /> = PUMP INSTALLATION 0 PUMP REPAIR E7 PUMP REPLACEMENT [� <br /> DISTANCE TO NEAREST: SEPTIC TANK [, SEWER LINES 6-0 � PIT PRIVY `~ <br /> SEWAGE DISP 5AL ^FIEL,D�SO-� .�. CESSI?OOL/SEEPA E PIT � OTHER �----- � � <br /> PROPERTY LIN .7PRIVATE DOMESTIC WELLS PUBLI�ESTIC WELL E � <br /> INTENDED USE, - TYPE OF WELL J; <br /> INTENDED - CONSTRUCTION SPECIFICATIONS <br /> --y. - Cable Tool Dia. of WeTI Excavation <br /> mestic/private r Dri-1,1,ed Dia. of Well Casing G; :3 <br /> Domestic/public aOrivenGauge of Casing <br /> Irrigation �2_Ro' <br /> ravenPacJDepth of Grout SealCathodic Protection tas ` <br /> Disposal y -- :Type �a_f Grout_ �3�h1 <br /> Other Other Information <br />- I eophysical' . 1 Surf ace,Seal'*1nsfa1,led b <br />'UMP INSTALLATION: y ';{ Contractor S CttDQ S" <br /> =-; Type of Pump <br />'f,lf1;P REPLACEMENT: []State Work Done <br />'UMP REPAIR: _ <br /> QState Work Done . ' <br /> fESTRUCTION OF WELL: Well Diameter ._.__ <br /> Describe Materia an Procedure Rpproximate Depth f <br /> ' I <br /> rP t <br /> hereby certify that I haveprepared this .applfcation- and that the work will be done in accordance <br /> ith :San Joaquin County Ordinances , State Laws, and Rules ,and Regulations of the San Joaquin Local <br /> eal.t.,h District. Home -owner or licensed .agent's s-ignatu're certifies the following: <br />,�"I/'certify that in the perfo.rma.nce-oi'-Tthe-work .for. -wh.i.ch thi-s-per-mit is issued, I shall <br /> • not employ any person in such manner as to become ,)subject to Workman's Compensation <br /> laws Califo i " <br /> WILL ALL A R T SP TIO RIOR TO GROUTING AND A. FINAL INSPECTION. <br /> IGNED DR W PL TIT4E: DATE: <br /> OT PL N ON REVERSE SIDE <br /> IASE I FO DEP RTM NT E ONLY . <br />'PLICATION ACCEPTED-BY ; 5# <br />)DITIONAL COMMENTS: <br /> DATE <br /> PHASE II GROUT INSPECTION <br /> ISPECTION BYPHASE III FINAL INSPECTIO <br /> QATE INSPECTION BY - <br /> 1426 Rev. 1277 , <br />