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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued _ <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 <br /> District. <br /> EXACT STREET ADDRESS 14239 East Ke-ttleman Zane CITY/TOWN Lodi <br /> Owner's Name Coweta Parkerson Phone <br /> Address 14239 East Kettleman Lane City Lodi <br /> Contractor' s Name Clark Well & Equipment Co. ,Inc-.i cense# 76602 phone 462-5597 <br /> IS CERTIFICATE OF WORKMAN"S COIMPENSATIO�! INSURANCE ON FILE WITH SJLHD? YES X NO <br /> TYPE OF WORK (Check) : NEW WELL EM DEEPEN ❑ RECONDITION ❑ DESTRUCTION <br /> WELL CHLORINATION 0 WELL ABANDONMENT Q OTHER J _ <br /> PUMP INSTALLATION 0 PUMP REPAIR❑ PUMP REPLACEMENT E3 <br /> DISTANCE TO NEAREST: 'SEPTIC TANK 400'+ SEWER LINES400,+ PIT PRIVY r <br /> `SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT t OTHER <br /> PROPERTY LINE -, PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL U1 <br /> INTENDED E TYPE OF WELL CONSTRUCTIONISPECIFICATIONS <br /> ,/— <br /> Industri al X Cable Tool _Dia. =of Wel Excavation 12" <br /> Domestic/private Drilled Dia. of Well Casing 12-1 <br /> Domestic/public Driven Gauge of Casing .186 <br /> X Irrigation Gravel Pack Depth of Grout Seal i # <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical = ' Surface Seal Installed b awe <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: CI5tate Work Done <br /> PUMP REPAIR: Q State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> t <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 fFiq 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 FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL4,INSPECTION. <br /> SIGNED € TITLE: Contractor iDATE: 28 Nov 78 <br /> - (DRAW PLUT. PTTN ON REVERSE- SIDE) <br /> FOR DEPARTMENT USE ONLY , <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE / a <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY C'.,,3, DATE INSPECTION BY DATE <br /> EH 1426 Rev. 12-77 __ <br />