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SAN JOAQUIN LOCAL HEALTH DIS'i R <br /> r F ICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Fe r.,;it No. 7Z- <br /> Telephone: <br /> Z- r <br /> Tele hone: <br /> p (209) 466-6781 <br /> APPLICATION FOR k'El i CONSTRUCTION OR PUMP PERMIT Dace Issued �> <br /> This Permit Expires 1 Year From Date Issued <br /> �Co»plete In Triplicate '11 oil 1",i <br /> ) <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 /> Joaquin County Ordirance No. 1862 and the Pules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS h/ X7-4 c ZCITY/TOWN <br /> Owner's Name L4 e — lax Phone <br /> Address /2 ��P i n� ��•r � City�c(, <br /> Contractor's Name � ,, �// ,� License# 29272 l-Phone_ 61 -7`7e <br /> IS CERTIFICATE OF WORK''AN'S CO"PENS IO'; INSL'^A'lCE ON FILE WITH SJLFiD' YES �0 <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 0 <br /> PUMP INSTALLATION ❑ PUMP REPAIRK) PUMP REPLACEMENT p �' 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY Or <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGEI� T OTHER <br /> PROPERTY LINE - PRIVATE D-FESTIC WELL PUBLIC 0 MESTIC WELL €' ' <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS i. <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing _ 1 <br /> Domestic/public Driven Gauge of Casing <br /> `__Irrigation Gravel Pack Depth of Grout Seal— <br /> Cathodic <br /> ea Cathodic Protection _ Rotary Type of Grout _ tt <br /> Disposal Other Other Information t <br /> Geophysical Surface Seal Instated by: <br /> t ,. <br /> PUMP INSTALLATION: ConLractcr t' <br /> Type of Pump v N. yU <br /> PUMP REPLACEMENT: []State Work Done [ <br /> PUMP REPA'R: ©State Work Dcne RjL <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth_ <br /> Describe Material and 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 w <br /> not employ any person in such manner as to become subject to Workman's Compensation <br /> f laws of California." <br /> �1 WILL CALL FOR A GROUT INSPECTION PRIOR_.TO GROUTING AND A FINAL INSPECTION. <br /> 'SIGNED ITLE: .� _l DATE:_ <br /> W ON REVERSE SIDE) <br /> OR DEPART .ENT USE ONLY <br /> PHASE I <br /> PPL I CATI ON ACCEPTED BY_ DATE <br /> ADDITIONAL COMMENTS: _ <br /> i PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY`'� c' DATE <br /> EH 1426 Rev. 12-77 1/78 2M <br /> T' <br />