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r�'------- SAN JOAQUIN LOCAL HEAL)H -ULS] RIL I <br /> FFiCE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. aZ <br /> Telephone: (20 9) 466-6781 <br /> a <br />' APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued//- <br /> This Permit Expires' 1 Year "From Date Issued <br /> Complete In Trip 'icate <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 <br /> "istrict. <br /> EXACT STREET ADDRESS 17155 Campbell Avenue CITY/TOWN Escalon <br /> Owner's Name dames D. Bell Phone (209) 838-2082 <br /> Address <br /> Ci ty .Escalon . . <br /> Contractor' s Name none License# Phone <br /> '.S CERTIFICATE OF WORKMAN'S tOMP61SATION INSURA"fCE ON FILE WITFI,-SJLHD?, YES ;10 <br /> TYPE OF WORK (Check) : NEW WELL W DEEPEN ❑ 0 Di N Q 'DESTRUCTION(� <br /> WELL CHLORINATION 0 WELL OTHER 0 <br /> PUMP INSTALLATION [N PUMP REPAIRNT❑ PUMP REPLACEMENT <br /> Q <br /> DISTANCE TO NEAREST: SEPTIC.TANK 150 • SEWER ES PIT PRIVY <br /> SEWAGE DISPOSAL-," FI-ELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL _ PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL "-__ CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 12" ' <br /> x Domestic/private' Drilled D"ia. of Well Casing 81r <br /> Domestic/publ i.6 i i,. Driven A Ga,Uge of;Casing p as-ic <br /> x Irrigation - „ Y__x_Gravel Pack " M Depth of,,Grout Sea <br /> Cathodic Protection x Rotary �;, 'Type of Grout 5 sack <br /> Disposal . 4:::._Other Other Information E�j. <br /> 4 <br /> Geophysical' ... Surface Seal Installed b self <br /> .� <br /> 'PUMP INSTALLATION: �Contractor none <br /> Type of ,Pump B_ erkley Submersible H.P. 10 <br /> PUMP REPLACEMENT: _ Q State Work Done <br /> PUMP REPAIR: Q State Work Done I <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate _De <br /> .pth <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordant( <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local <br /> Health District._ Home owner oqr 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 FORA GROUT INS TION PRIOR O GROUTING AND A FINAL INSPECTION. <br /> SIGNED James D. Bell <br /> TITLE: Owner DATE: 3 0 8 <br /> DR W PL T L WON REVERSLSIDE <br /> PHASE I FOR DEPARTMENT USE ONLY" <br /> APPLICATION ACCEPTED BY <br /> " 71 <br /> { <br /> ADDITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTI N PHASE I-11,FoINAL INSPECTION <br /> INSPECTION BY DATE__fINSPECTION BY DATE <br />=H 1426 Rav_ 19-77 . - I� <br />