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�!N JOAQUIN LOCAL HEALTH DISTRIC <br /> { FFICE USE: 1601 �� Hazelton Ave. , Stockton, CA '05 Permit No.Z _ -5 a <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued -.z - 7k <br /> � # This Permit Ex 'ires 1 Year From Date issued <br /> Complete In Triplicate <br /> �)dlorainostail workherein hereby <br /> made <br /> tthe <br /> esSan <br /> Joaquin Local Health District for a permit to construct <br /> This application is made in compliance with San <br /> Joaquin County Ordinancc�e N 18 and the Rules and Regulations of the San Joaquin Local Health <br /> Fstrict. , <br /> LXACT STREET ADDRESS Tahama Village, .10780 North <br /> Highway 99 CITY/TOWN Stockton <br /> Finer's Name Mike Carney Phone <br /> 74 New Montgomery St, Suite 102 San <br /> �Jdress. City Francisco <br /> ntractor' s Name Clark Well & Equip. Co. , Inc. Li cense#76602 Phone f 2-5597 <br /> .S CERTIFICATE OF WORKMAN'S COMPENSATIOIJ INSURANCE ON FILE WITH SJLHD? YES X IN <br /> (PE OF WORK (Check) : NEW WELL[A DEEPEN ❑ RECONDITION [3 DESTRUCTION❑ ~ <br /> WELL CHLORINATION ❑ . WELL ABANDONMENT Q OTHER ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT <br /> [STANCE 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 2" <br /> Domestic/private Drilled Dia. of Well Casing <br /> -f-Domestic/public Driven Gauge of Casing boo <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection --Rotary Type of Grout Cement <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: OlFiers <br /> SUMP INSTALLATION: Contractor <br /> iP Type of Pump H.P. <br /> PUMP REPLACEMENT: [I State Work Done i <br /> FJMP RE-PAIR: ❑State Work Done <br /> uESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure r <br /> I- hereby certify that I have prepared this application and that the work will be done in accordant <br /> rith San Joaquin County Ordinances, State Laws , and Rules and Regulations of the San Joaquin Local <br /> �alth 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 /> . WILL G FOR INSP CTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> GNED TITLE: Contractor DATE: 28 August 78 <br /> (URAW PLOT PLTN ON REVERSE SIDE J <br /> FOR DEPARTMENT USE ONLY <br /> P--!ASE I <br /> ! 'PLICATION ACCEPTED BY2"dil L04t= DATE by <br /> .JDITIONAL COMMENTS : <br /> PHASE 4,1, GROUT INSPECTION PHASE II FINAL INSPECTION <br /> FISPEGTION BY DATE__a1:6-12 INSPECTION BY DATE -(o-)9 <br /> CL 1AOc rt .. ,n -rte , 1-7 0 0aR <br />