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SAN JOAQUIN LOCAL ;HNLTH DISTRICT <br /> FFIC USES - 1 1601 E. Hazelton Ave. , Stockton, ,-� <br /> _,--� CR 95205 Permit :Nq.'� <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR TELL CONSTRUCTION OR PUMP PERMIT Date Issued,5_/4_-72_ <br /> This .Permit. Ex ires -I 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 /> I <br /> and/or install the work herein described. This application is made in compliance with San` <br /> ,oanui n County Crdinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health i <br /> District. <br /> EXACT STREET ADDRESS ,•�9' CITY/T04�fN <br /> -- r <br /> Owner' s Name Phone J-''— <br /> Address City <br /> Contractor's Name , License#�2,0,g,0 Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION I�dSURA"•1 E ON FILE WITH SJLHD? YES <br /> �_ <br /> NO <br /> TYPE OF WORK (Check) : NEW WELLIg DEEPEN ❑ RECONDITION ~ <br /> ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENTl-] OTHER ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT - <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE-RI_T. OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> ustrial Cable Tool Dia. of Well Excavation . <br /> Domestic/private Drilled Dia. of Well Casing s <br /> Domestic/public Driven - Gauge of Casing <br /> Irrigation Gr vel Pack Depth of Grout Seale <br /> Cathodic Protection �Ratary Type of Grout - <br /> Disposal Other Other Information ,.. <br /> Geophysical Surface Seal Instal ed b <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H. . <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: ;y ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Mater-i—aT—a—n-d Procedure Approximate Depth <br /> I hereby certify that I have prepared this application and that the a work will be done in accordance <br /> 0th San Joaquin County`-.;•Ordinances , State Laws, and Rules and Regulations of the San Joaquin Local <br /> lealth 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 />[ WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. ` <br /> iIGNED TITLE: DATE: <br /> DR W REVER <br /> PLOT PLTN- SE SIDE <br />�HA'SE I FOR D1=P RTM T USE ONLY <br /> APPLICATION ACCEPTED BY DATE_���-�� <br /> 4DDITIONAL COMMENTS : <br /> Yl <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> NSPECTION BY DATE INT ION BY DATEel . W ' <br />'N 1/1'J G n of nC W'PiSlti L�P��' 1 t� 'Q �. <br />