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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 3 7 <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 /> and/or install the work herein described. Y. This application is made in 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,0ka on CITY/TOWN/, <br /> Owner's Name -AlPhon 6% /g <br /> Address ��� �� �r .- <br /> C i ty 17 •� <br /> Contractor's Name ,� License# ?�i Phone c f 6Y <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIOIN INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL C1 DEEPEN Q RECONDITION ® DESTRUCTION E3 <br /> WELL CHLORINATION p WELL ABANDONMENT p OTHER 0 � <br /> PUMP INSTALLATION M— PUMP REPAIR❑ PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> Jdp� SEWER LINES 1. 4 PIT PRIVY as <br /> SEWAGE DISPOSALFIELDyf-f CESSPOOL/SEEPAGE PIT OTHER <br /> f <br /> PROPERTY LIN RIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS + <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <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 e Surface Seal Insta Ted b <br /> PUMP INSTALLATION: Contractor A <br /> 12 a Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Y Approximate Depth <br /> Describe Materia an 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 FOR A GROUT INSPECTION PRIOR TO GROUTING ANDA INAL INSPECTION. <br /> SIGNED TITLE:. DATE: <br /> --FDRAW PLT PLAN ON REVERSE SIDE <br /> PHASE I a. FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE_ „3-�7� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY /° DATE = ' <br />:H 1426 Rev. 12-77 <br />