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M. SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> r <br /> �Q FP_ 0 FICE USEN 1601 E. Hazelton Ave.., Stockton, CA 95205 Permit No. -� <br /> .. s Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> (Complete In Triplicate) <br /> n 25-- 0 zo-n <br /> Application i5 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. ' t <br /> CS'Z- I A) C- c�asrcoc� •�'� <br /> EXACT STREET ADDRESS. Westgate Landing. ParkrR4E-T3N Section 12 CITY/TOWN Terminous <br /> Owner' s Name San Joaquin County Parks & Recreation Dept. Phone 944-2118 <br /> — - � ----fes <br /> Address 18$0 E: Hazelton Ave <br /> City—" Stockton <br /> Contractor' s NIi ame Clark Well & Equipment Co . , IncLi cense# '76602 Phone-462-559Z <br /> IS CERTIFICATE OF I1'dSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (,Check) : NEW WELL Lam_ _:sDE.EPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT-ED OTHER ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT El <br /> DISTANCE TO-NEAREST: SEPTIC.'JANK none ,SEWER LINES none PIT _PRIVY <br /> SEWAGE DISPOSAL FIELDCESSPOOL/SEEPAGE�PIT OTHER��_ <br /> PROPERTY LINES-50RIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL I w= CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 12 8'1 <br /> Domestic/private Drilled Dia. of Well Casing 8 81T <br /> x Domestic/public Driven . . Gauge of Casing Class 160 .Plastic <br /> Irrigation Gravel Pack Depth of Grout Seal to im erviuos cla ' <br /> Cathodic Protection x� Rotary Type of Grout Bariod Aqua- Gel Bentoni I <br /> Disposal _ Other Other Information j <br /> Geophysical Surface Seai Installed by: <br /> PUMP INSTALLATION: Contractor ' <br /> Type of Pump H.P. <br /> z <br /> PUMP REPLACEMENT: ❑ Statte Work Done <br /> PUMP REPAIR: �. <br /> _ ❑State Work Done <br /> DESTRUCTION DF 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 accord c <br /> with San Joaquin County Ordinances , State Laws , and Rules and' Regulations of the San Joaquin Lo I <br /> Health District. !dome owner or licensed agent' s signature certifies .the following: <br /> "? 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 C lifo 17. � _ <br /> I WILL CA A OUT TIO PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNEDTITLE: Vice-Pres - Clark DATE:_.C) Julv 12._9-9.7_g <br /> 'D W; PL T PLN ON REVERSE SIDE <br /> FOR DEPA TMENT tbE ONLY <br /> PHASE ' <br /> APPC ICATION 'ACCEPTED $Y . yDATE <br /> ADDITIONAL COMMENTS : . I <br /> PHASE I I GROU'T.,,IN:SPECTION. PHASE III FINAL INSPECTIO J / <br /> INSPECTION BY DAT E -lLy� �'�' INSPECTION BY, DATE , <br /> 31/ <br /> EN 14 26 Rev: 9/78 s 5/79 2M <br />