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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> TOR FFICE USE: /1"'160I E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone:'--(209) 466-6781 <br /> APPLICATION FOR TELL CONSTRUCTION OR PUMP PERMIT Date Issued_LZy)R- <br /> This Permit Expires 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. 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 4 <br /> C�istrrct. �� Z <br /> EXACT STREET ADDRESSCITY/TOWN_��./ <br /> Owner' s Name AAAA � Phone <br /> �_ 1_n <br /> Address <br /> City <br /> Contractor's Name License phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIOiN INSUR •10E ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPENPI RECONDITION Q DESTRUCTION <br /> WELL CHLORINATION ❑ WELL ABANDONMENT O OTHER ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANKS SEWER LINES_ PIT PRIVY ---- <br /> SEWAGE DISPOS L+ FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> • PROPERTY LINO a PRIVA E D MESTIC WELLSPUBLIC DOMESTIC WELL �-- <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation u <br /> Domestic/private Drilled Dia. of Well Casin ++ <br /> Domestic/public Driven Gauge of Casing �� <br /> _Irrigation Gravel Pack Depth of Grout Seal J � �� <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Instal ed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: Q State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe MateriaT 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 /> f WILL C FOR A R I P TION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> 5IGNE TITLE: iz DATE: <br /> DR W PLOT PLAN ON REVERS SIDE <br />'RASE I FOR APARTMENT USE ONLY <br /> PP��-PLICATION ACCEPTED BY DATE <br /> kDOITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III INAL INSPECTION. <br /> NSPECTiON BY�� DATE INSPECTION BY DATE 2f <br /> H 1426 Rev. 12-7ZG <br />