Laserfiche WebLink
V SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 79- 1/ 1;-O <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued , <br /> This Permit Ex fires 1 Year From Date Issued <br /> Complete In rip irate <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 Kettleman Lane 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. ,Ine{icense# 76602 Phone 462-5597 <br /> IS CERTIFICATE OF WOPKHAR'S COMPENSATION INSURAMCE ON FILE WITH SJLHD? YES X NO <br /> TYPE OF WORK (Check) : NEW WELLEM DEEPEN ❑ RECONDITION ❑ DESTRUCTION[z/,//S-/-2? <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ED OTHER❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK 400•+ SEWER LINES 400'+ PIT PRIVY T <br /> SEWAGE DISPOSAL FIELD CESSPUbL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL— S <br /> INTENDED USE TYPE OF WELL CONSTRUCTIONISPECIFICATIONS <br /> In use Cable Tool _Dia. •of Wel Excavation 12" `— <br /> DOmestiC/private. Drilled - Dia.of Well Casing ' 12" <br /> Domestic/public Driven Gauge of Casing .188 <br /> X Irrigation Gravel Pack Depth of Grout Sea # <br /> Cathodic Protection Rotary Type of Grout TM <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Instawe <br /> PUMP INSTALLATION: Contractor �.. <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and 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 f6llowing: <br /> "I certify that in the performance of the work for which tfii� 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." i del <br /> I WILL CALL FOR A GROUT INSPE TION PRIOR TO GROUTING AND A FINAL4-INSPECTION. <br /> SIGNED TITLE: Cdntractor i DATE: 28 Nov 78 <br /> _ — ") W PL T ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONL • <br /> PHASE I �J <br /> APPLICATION ACCEPTED BY 17,417 DATE / ,; P <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY C_ moi. DATE INSPECTION BY ("D- DATE <br /> - EH-1426 Rev.. 12-77 `"� d" /- r-�f ��>�78 2 <br />