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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued . <br /> This Permit Expires 1 Year From Date Issued <br /> 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 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. ; <br /> EXACT STREET ADDRESS 10052 South Jack Tone "Road CITY/TOWN Stockton <br /> 934 <br /> Owner's Name James D. Vargas Phone 462-4' <br /> Address 10052 South Jack.. Tone Road City Stockton <br /> Contractor' s Name Clark Well & E ui . , Co. , Inc. Li cense# 76602 Phone 462- <br /> IS CERTIFICATE Q1- WORKMAN'S CO"•1PENSATIQ'N II`3SURAINCE ON FILE WITFI SJLHD? YES X <br /> TYPE OF WORK (Check) : NEW WELL 0 QUEEN ®- RECONDITION.,(]'' DESTRUCTION EJ <br /> WELL CHLORINATION © WELL ABANDONMENT-0 OTHER.Q - + <br /> PUMP INSTALLATION El PUMP REPAIR❑ PUMP REPLACEMENT [a ' <br /> DISTANCE TO NEAREST: SEPTIC TANKS SEWER LINESI 0• PIT PRIVY"----- == 3 0 <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PiT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> iNTEHDED'IJ E' ' ' `` YPE 'O �W LL' ' ' COf� 7RlICTfO�J S`�t ICATI0NS, <br /> Industrialx� —.Cab-5 Tool -Di-aof-Wel 1- --Excavation " s <br /> X Domestic/p'ri'vate° f Drilled - Di 176f-Wel 1`V Cas'i_ng 6 _i s <br /> Domestic/public Driven- Gage of ;Casing12 <br /> Irrigation Gravel Pack Deth of Grout Sea <br /> Cathodic Protection � °Rat'ary Type of Grout Bentoni.t;e,- <br /> Disposal Othe"r Other Information <br /> Geophysical I$ r-face Seal Insta. ed b { <br /> PUMP INSTALLATION: Contractor ` <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: []State Work Dore <br /> PUMP' REPAIR: ❑State Work Done p ., <br /> DESTRUCTION OF 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 accordance <br /> with San Joaquin County Ordinances , State Laws ,_a_n_d Rules and Regulations of the SanJoaquin 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, Iishall <br /> not employ any person in such manner as to become subject to Workman's Compensation <br /> lawsCalifornia." <br /> i I WILL CA FOR A UTI PECT N PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: Contractor DATE: A ri1 1979 <br /> -- (DRAW PLOT PL N ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ATE 7 <br /> APPLICATION ACCEPTED BY I a-y. <br /> ir <br /> ADDITIONAL COMMENTS : ' <br /> PHASE II GROUT NSPECTION pHA I F L INSPECTION <br /> INSPECTION BY , DATE INSPECTION BY DATE <br /> MA 1 A79 Dctf 1 9-77 _, .__ <br /> 1/78 2M <br />