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� r <br /> SAN JOAQUIN LOCAL- HEALTH UISFRIC1 <br /> ' Permit No. 79-53b <br /> OFFICEEQR USE: 1601 E. Hazelton ,Ave.., Stockton, CA 95205 - <br /> 'j Telephone:. , (209)- 45676781 <br /> Date Issued �--2 - <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Y <br /> This Permit -Ex ires1. Year. From .Date:.issued { <br /> i 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 s .,mof the San Joaquin Local Health compliance with San <br /> Joaquin County Ordinancer,rlo. 1862 and the Rules and, Regulations of the i <br /> District. <br /> EXACT STREET ADDRESS 8618 Treasure CITY/TOWN Stockton <br /> Phone 931-0 <br /> Owner' s Name Dr. Boetter <br /> , ' <br /> City Stockton -. . <br /> Address` 8618 Treasure r <br /> Contractor' s Name Clarke Well & E ui .Co. ,Inc. Li cense#76602 Phone 462-5597 i <br /> IS• CERTIFICATE OF WORKMAN'S COMPENSATIOIN INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check1: NEW WELLM-_DE Q N_0 .- RECONDITIDN ❑ . DESTRUCTION[ ,. <br /> WE ' <br /> LL CHLORINATION 0 WELL ABANDONMENT ' OTHER 0 t <br /> PUMP INSTALLATION L PUMP REPAIR❑ PUMP REP.LACE,MERT-01 r: � <br /> '� �� PIT PRIVY W <br /> DISTANCE-TO NEAREST: SEPTIC TANK±L-O SEWERFLINES'f-1OQ_- <br /> SEWAGE DISPOSAL FIELDS CESSPOOL/SEEPAGE PITS OTHER <br /> PROPERTY LINE IPRIVATE DOMESTIC WELL 1 PUBLIC`DOMESTIC WELL `' <br /> INTENDED USE + TYPE OF WELL CONSTRUCTION SPECIF_IG},4T,IOIVS <br /> Industrial I Cable Tool Dia. of Well Excavation ' 0 <br /> _Domestic/private Drilled -.,. - Dia. of Well Casing ` '..6" 8" <br /> Domestic/public Driven Gauge of Casing"*- ''I" ' S tee i e <br /> Irrigation Gravel Pack Depth of�Grout Sealk,,- o'l >' <br />' Cathodic Protection x Rotary Type of Grout Zik=Gel ' entoriite <br /> -Disposal <br /> Other Other Information <br /> Geophysical Surface 5ea1'*Installed b <br /> : PUMP INSTALLATION: Contractor ~" H.P. <br /> Type_ of Pump <br /> PUMP REPLACEMENT: Q State Work Done <br /> PUMP REPAIR: QState Work Done ' l <br /> DESTRUCTION OF WELL: -"""Wel'l­f Diameter 6" Approximate Depth <br /> i Describe Materia ani" Proce ui^e SAID <br /> a�. Tb 0r <br /> rdanc <br /> II hereby .certify. that I have prepared this application and that the work will�be done. in Joaaccquin <br /> Local <br /> with San Joaquin County: Ordinances , State Laws , and Rules and Regulations of theiSan Joaquin Local <br /> Health District. 'Home �owner'�orF l i cen'sed--agent-''s-signature certifies the following' <br /> "I certify that.an ..in"the performance of the work for which this per <br /> is issued,� I shall <br /> not employ y ,person. in..s.uch manner. as to become subject to Workman's Compensation <br /> laws California.'," a <br /> I WILL CALL F R AMG OUT, INSPECTION PRIOR`T.O' GROUTING 1.AND A FINAL �NSpECTION. <br /> S <br /> T ITL-E:_C] UM--- . �. DATE.` <br /> ISIGNED <br /> DRAW PLT PL N ON REVERSE SIDE <br /> F FOR DEPARTMENT, USE ONLY-'� <br /> .;.- ";�" - DATE_., Z <br /> APPLICATION ACCEPTED BY. <br /> ' ADDITIONAL COMMENTS: <br /> PHAS4 JI GROUT INSPECTION PHA5E 111FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE - L�-1 <br /> 78 2M <br /> �r�I w Anc ., ,n.... 1 9._77 <br />