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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> _7FM� FF.1 E USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone:. (209) 466-6781 <br /> APPLICATION FOR WEC.O,NSTQb CTION OR PUMP PERMIT Date Issued <br /> LL <br /> . This Permit*' Ex ires '1 Year From Date Issued` <br /> -� Com lete In Triplicate <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or. i.nstall 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. s', U7�`�'71/7Lii✓f -7;- 6 <br /> 6g5. �.J . CITY TOWN <br /> EXACT STREET ADDRESS. �U o fo w r _ Tr <br /> Owner's Name Lod e-5;Lale., Phone z1I 49 <br /> Address emssCity <br /> Contractor' s Name - License#, Phone "- '-a, <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL W DEEPEN 0 RECONDITION ❑. DESTRUCTION d <br /> WELL CHLORINATION [] WELL, ABANDONMENT*O OTHER 0 -- ` <br /> PUMPINSTALLATION�, PUMP REPAIR EJ___PUMP _REPLACEMENT C� N <br /> DISTANCE TO NEAREST: _r ;SEPTIC TANKw. SEWER LINES PIT PRIVY `s <br /> k ; . , SEWAGE DISP SAL FIELD CESSPOOL/SEEPAGE TI-77— <br /> T &- OTHER <br /> IPROPERTY-LINE' --PRI-VAT DOMESTIC WELL,0 - PUBLIC DOMESTIC WELL <br /> • : INTENDED <br /> USE TYPE OF WELL p CONSTRUCTION-SPECIFICATIONS s <br /> . Indus,trial Cable Tool Dia. of Well Excavat on A <br /> t Domesti-c/private ; z'—iD.ri11ed--` Dia. of Well CasingT <br /> `Domestic/public � -Driven , Gauge of Cas4-ng-. - - - <br /> Irrigation Gravel Pack C Depth of Grout. Seal 11., <br /> Cathodic Protection Rotary ¢ Type of-Grout <br /> Disposal ..Other Other Information <br /> Geophysical Surface Seal I,.ns'ta,1..1,ed b <br /> PUMP INSTALLATION: Contractor �- <br /> Type of Pump H.P. <br /> - o <br /> PUMP- REPLACEMENT: b State Work Done <br /> PUMP REPAIR:, OState Wor�kkDpne <br /> I� A <br /> DESTRUCTION OF WELL: "`�"WeT1'­Diamet'er Approximate Depth <br /> Describe Materia -and Proce u°re--- <br /> I hereby certify that I have prepared this applidW on and that the work will be done in accordan( <br /> with San Joaquin County Ordinances , State Laws, and Rules and Regulations of the San Joaquin Local <br /> Health District. Hoye 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 OUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> f �. <br /> j SIGNED r TITLE: DATE: -- <br /> DRAW PLT PLN ON REMISE SIDE) <br /> ` FOR DEPARTMENT-USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED <br /> ADDITIONAL COMMENTS: <br /> PHASE II GR UT INSPECTION :` PHASE III FIML INSPECT12 <br /> INSPECTION 8Y DATE INSPECTION BY DATE 6 <br /> 1=�7$ 2M <br /> "a 1426 Rev- 12-77 ' - � <br />