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� , � SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> YbR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, -CA'_ <br /> 95205 Permit No. 79 3p/ <br /> Telephone: -(209) 466-6781 <br /> Date Issued , <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit Expires 1 Year From Date Issued <br /> Complete In Triplicate <br /> Application is hereby made to. the San Joaquin Local HealthDistrict for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San <br /> ,oaqui n County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS 3437 So. Airport Way CITY/TOWN Stnpkton <br /> Owner's Name Parsons Of California Phone cog-ni An <br /> Address 3437 S'o. Airport Way City Sto _kton <br /> Contractor's Name Clark Well & Equipment Co. , IncLicense# 76602 Phone 462-5592 <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELLS] DEEPEN ❑ RECONDITION DESTRUCTION❑ <br /> WELL CHLORINATION ❑ ELL ABA ENT OTHER 0 W <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT ❑ __J <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 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 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven - Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter 0^ Approximate Depth 180' <br /> Describe Material and Procedure fill to -50 with Sand & Pea Gravel <br /> 0 to -10 5 sack mi 0 to 0 is nemented pit to be fillaA <br /> ,n 1pcKri <br /> I hereby certify that I have prepared this application and that the work will belone in accor anc <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 CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: 7Q <br /> (DRAW PLOT PLAN-ON REVERSE SIDE <br /> FQ9 DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIOW PHASE III FINAL INSPECTION <br /> INSPECTION BY Al 4 DATE INSPECTION BY 9p DATE b AV <br /> EH 1426Rev. 12-77 1 78 2M <br />