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d-G!0A <br /> SAN JOAQUIN LOCAL HEALTH UISTRICI- - <br />__EQR-QFFICE USE: 1601 E. Hazelton Ave. ,' Stockton, CA 95205 Permit No. 7 '�'-/,// <br /> - Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Expires 1 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 /> 'eanuin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS 8988 S . Priest CITY/TOWN Frecch Camp <br /> Owner' s Name Randy Robinson Phone 982-0849 <br /> Address 9160 S . Priest City French Camp - <br /> Contractor' s Name Clark Well & Equip-Co. ,Inc License# 76602 Phone 462-5597 <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELLS DEEPEN ❑ RECONDITION ❑ DESTRUCTION d °0 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ED OTHER 0 �0 <br /> PUMP INSTALLATION C7 PUMP REPAIR❑ PUMP REPLACEMENT Q °Q <br /> DISTANCE TO NEAREST: SEPTIC TANK F SEWER LINES 3V f PIT PRIVY <br /> SEWAGE DISPOSAL FIELD -6-0 -f CESSPOOL/SEEPAGE PIT . OTHER <br /> PROPERTY LINW PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL- <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation 10 54b" <br /> X Domestic/private Drilled Dia. of Well Casing 0 51b" <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection x Rotary Type of Grout Benton e <br /> Disposal Other Other Information <br /> Geophysical Surface -Seal Installed by: <br /> PUMP INSTALLATION: Contractor Stowell Equipment Co, ,Inc. <br /> Type of Pump- Sub H.P. i <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: ❑State Work Done ; <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth _ <br /> Describe Material and .P.roce ure - <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 Calif ia." <br /> I WILL C&L/FOfk 0 ECT N PRIOR TO -GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE : V. P 6'' DATE: ( e,2 <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY� ,�J� _ DATE 6>-2,;1 `7`T <br /> ADDITIONAL COMMENTS: <br /> PHASE II, GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BYA .... DATE INSPECTION BY DATE 7_3 <br /> EH 1426 Re 2- C�' 78_ 2M <br />