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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE 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 5_ <br /> This Permit Ex i.res I Year From Date Issued <br />� -. Complete . In Triplicate " <br /> lApplication is hereby made to the San Joaquin Local H— IHea <br /> and/or install the work herein described. - This applAcationDistmade °i.nISr ICE, lorcompliancea permittwithnstrSanGct <br />[ loaquin County Ordinance No. 1862- and the .Rules and Regulations of the San Joaquin Local. Health <br /> District. <br /> EXACT STREET ADDRESS 4810 East Shippee Inane <br /> CITY/TOWN Stockton <br /> Owner' s Name JIM KIETZKE <br />' Address 711.7 Pacific Avenue Phone 478-2320 <br /> City Stockton <br /> Contractor' s Name Clark Well & E ui . Co. , Inc. License# 76602 Phone 462- �1 <br /> IS CERTIFICATE OF WORKIIAN'S COMPENSATIO"l INSURANCE ON FILE WITH SJLHD? YES NO <br /> I <br /> TYPE OF WORK (Check) : NEW WELL L4 DEEP.EN0 RECONDITIONDESTRUC ; <br /> WE L—CHb0RRI NATION [ = ==WE1=L�-3ABA DONMEN r� OTH£RT(� N d; <br /> PUMP INSTALLATION 0 PUMP REPAIR❑ PUMP REPLACEMENT [j <br /> ` <br /> DISTANCE TO NEAREST: SEPTICITANK Or <br /> 60'+ SEWER LINES 60'+PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LIN£ -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC UE—LL — <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIE. <br /> Industrial Cable Tool Dia. of Well £xca}atian SPECIFICATIONS <br /> x Domestic/private Drilled 1i0 <br /> Domestic/ ublic Dia. of Well Cas7ngs._, <br /> P �-. Driven "- Gauge of Casi ng� r ,y, � ;12 <br /> Irrigation i Gravel Pack .,_D.epth,of Grout "Seal �0I � <br /> Cathodic Protection i x Rotary Type of Grout Bentonite i I <br /> Disposal I Other ' Other Information <br /> Geophysical Surface Sealn <br /> # Insta7led b •rp_ <br /> PUMP INSTALLATION: Contractor - <br /> Type of- Pump <br /> PUMP REPLACEMENT: Q State Work Done T ' <br /> PUMP REPAIR: ' — <br /> D£ST ❑State Work Done i � <br /> RUCTION OF; WELL. Well Diameter <br /> Approximate DeFth <br /> Describe Materia and Proce ure <br />[ hereby certify that I have prepared this application and that the work` will be done in accordance <br /> pith San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local , <br /> iealth District. Home owner or licensed agent's signature certifies the; following`:7 <br /> I certify that in the performance of the work for-which th7_s_Pe-r_mitA s ?i ssu�ed,I shall- <br /> - <br /> not employ' any person in such manner as to become subject to Workman's Compensation t <br /> laws of California. " _# f <br /> WILL L FOR GR INS CTION PRIOR TO GROUTING AND A FINAI. INSPECTION. <br /> IGNED ' <br /> TITLE : Contractor DATE: 5 June 79 <br /> t DRAW PLOT PL N ON REVERSE SIDE <br /> HASE I F DEP TMENT USE ONLY <br /> PPLICATION ACCEPTED BY = ' <br /> DDITIONAL COMMENTS : DATE <br /> PHASE II GR T INSPECTION PHA E III FINAL INS ECTION <br /> VSPECTION BY DATE °� INSPECTION BY <br /> DATE <br /> 1 1426 _-Rev. 12-77 _y ' <br />