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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE 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 /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS 7500 Meadow Ave CITY/TOWN <br /> Owner's Name Mr. Jahn Hazard Phone 4.77-1568 <br /> Address 7500 Meadow Ave City Stockton <br /> Contractor's Name Clark Well & Equipment Co. Snbicense# 76602 Phone 462-5597 <br /> IS CERTIFICATE OF WORKMAN'S CO,11PENSATIO1111 INSURA.1-lCE ON FILE WITH SJLHD? YES X NO <br /> TYPE OF WORK (Check) : NEW WELL L DEEPEN L3 RECONDITION Q DESTRUCTION[j <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION 0 PUMP REPAIR 0 PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK 60+ SEWER LINES PIT .PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER � . <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL o <br /> INTENDED USE TYPE OF- WELL CONSTRUCTION SPECIFICATIONS 4 <br /> Industrial Cable Tool Dia. of Well Excavation <br /> X Domestic/private Drilled Dia. of Well Casing__ 1. <br /> Domestic/public Driven Gauge of Casing 12 <br /> Irrigation Gravel Pack Depth of -Grout• Seal 50 <br /> Cathodic Protection X Rotary Type of Grout Bentonite , <br /> Disposal Other Other Information <br /> Geophysical Well Drilled Jan 75 Permit Seal Installed by: ; <br /> PUMP INSTALLATION: Contractor s <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: -OState Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth ' <br /> Describe Material arid 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 /> I WILL CW FO T INSPJZCTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: i DATE:: <br /> (DRAW PLOT PL N ON REVERSE SIDE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY - DATE ;4/ L7P'- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE11�$� <br /> EH 1426 Rev. 12-77 1 178 2M <br />