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]� SAN JOAQUIN' LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 <br /> Permit No. _�33a <br />-FOR 0 <br /> Telephone: (209) 466-6781 Date Issued79/ <br /> APPLICATION FOR TELL CONSTRUCTION OR PUMP PERMIT <br /> This- Permit Ex ires 1 Year From Date .Issued : <br /> Complete in Triplicate <br /> is he ma San Joaquin Local Health District for a permit to construct <br /> ApplicationY lication is made in compliance with. San <br /> and/or install the work herei rid descri bed This ap.p <br /> Ifla4 ;;n County Lrdinance ��a. 1862 and the Rules and �Regulations` of the San Joaquin. Loca1 Health <br /> Distr'ct. cITY/�owN <br /> � <br /> EXACT STREET ADDRESS , <br /> Q � <br /> Phone ' <br /> Owner's Name- <br /> `.�. Ci ty <br /> Address <br /> �;= i Phone <br /> Contractor' s Name r i cense� <br /> � <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO.I INSURA"aCE-Ofd' FILE WITH SJLHD? YES N <br /> TYPE OF WORK (Check) : NEW WELL 52:, DEEPEN ❑ RECONDITION [] DESTRUCTION <br /> WELL CHLORINATION Q WELL ABANDONMENT 0 OTHER 0 <br />` PUMP INSTALLATION 0 PUMP REPAIR❑ PUMP REPLACEMENT Q <br /> DISTANCE TO NEAREST: SEPTIC TANK SAL FIELD` SEWER LINEcr�"� -1/ PIT PRIVY <br /> SEWAGE DISPOSsSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE _DOMESTIC WELL�� —' PUBLIC DOMESTIC WELL <br /> TYPE OF WELL ' ` CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE , r' Dia. of Well Excavation <br /> {,? Industrial }Cable Tool <br /> Dia. of Well Casing <br /> Domestic/private . —Drilled <br /> Driven Gauge of Casing <br /> Domestic/public Gravel Pack I Depth of Grout Seal <br /> Irrigation —RotaryType of Grout �✓ <br /> thodic <br /> Protection f � Other Information ` <br /> p Other _ Surface Seal Insta1Ied,b .✓ <br /> Geophysical <br /> RUMP INSTALLATION: Contractor : . H <br /> Type bf Pump s� <br /> PUMP REPLACEMENT: (State Work iD ne <br /> PUMP REPAIR: ED State Work Dome <br /> DESTRUCTION OF WELL: AelI Diameter <br /> t --� Approximate Depth <br /> Descria an. Procedure <br /> I hereby certify that I have prepared thi's app <br /> lication and"that the work will be done in accordant <br /> with San Joaquin County Ordinances, <br /> State -Laws , and Rules and Regulations of the San Joaquin Loca• <br /> _ __ . <br /> t Heal tK-Di strf ct. 'H-6me"owner or l-ieensed agerit',s s i nature certifies the "fol l ow'�ng <br /> "I�certifyathat...in -the� perfo.rmance"£of `th ',.,work forw-hich. tKis_.pe.rmit-is ,.i.s.sued, 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 CAL FOR A GRO `INSPECTIONfPRIOR TO GROUTING AND A FINAL INSPECTION. DATE: 1 S <br /> N. 11-1 T I TLE: <br /> SIGNED DRAW PLOT PLN ON REVERS IDE <br /> ,, V', - •� FOR DEPARTMENT USE ONLY <br /> , PHASE I X. �~ DATE <br /> APPLICATION ACCEPTED BY J -"- <br /> � ADDITIONAL COMMENTS: PHASE II FINAL INSPECTION <br /> PHASE Ii GROUT INSPECTI© DATE 0_6-`18 <br /> INSPECTION BY 1 DATE INSPECTION BY <br /> IZ <br /> 78 2N <br />