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SAN JOAQUIN LOCAL HEALTH DIS'T'RICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No 1- , <br /> Telephone: (209) 466 -6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued --7 <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 4099 South Kaiser Ra-ci. CITY/TOWN Stockton ; <br /> Owner's Name-Elgin Yturri Phone 948-0416 <br /> Address 4099 South Kaiser .Road CityStockton s <br /> Contractor's Name''Clark Well & Equipment Co. ,IncLicense#76602 Phone 462-5597 <br /> IS CERTIFICATE OF WOE'KMAN'S COMPENSATIOM INSURANCE ON FILE WITH SJLHD? YES XX NO <br /> TYPE OF WORK (Check) : NEW WELL U DEEPEN ❑ �, RECONDITION ❑ DESTRUCTION❑ <br /> •—.-----WELL-CHLOR-I-NA-T-IDN-0-- --WE-LL`ABANDONMENT 0-----OTHER-ISI- --- -�- - -- -- <br /> PUMP INSTALLATION ❑ PUMP- REPAIR❑ PUMP REPLACEMENT [� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER \j , <br /> PROPERTYbLINE,-. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE + TYP'E_OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 16 <br /> Domestic/privateE.., Drilled Dia. of Well Casing -� <br /> Domestic/public + Driven Gauge of Casing <br /> X Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection + Rotary Type of Grout <br /> Disposal i Other Other Information <br /> Geophysical I _.. _ _- —-Su.r_fa,ce_Sea1. _Instal ed -by.: <br /> PUMP INSTALLATION: Contractor f . <br /> Type of Pump t H:P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ?QState Work Done <br /> DESTRUCTION OF WELL: , Well Diameter '� _t \,Approximate Depth <br /> - Describe Material and Probe Uee <br /> I hereby certify that I' have prepared this application and that the work will be done in accordance <br /> with San Joaquin CountylOrdinances , State Laws , and Rules and Regulations of the San Joaquin 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, I shall <br /> not loy any pegs' n. such manner as to become subject to Workman's Compensation <br /> 1 o Californi . F i <br /> I WI L OR A G NSP CTIO RIOR TO GROUTING AND A FINAL INSPECTION. <br /> AY <br /> SIGNE TITLE: AW0151Z DATE: Z3 HAR4 <br /> (DRAW PLOT PL N ON REVS SE SIDE <br /> F R DEPARTMENT USE ONLY <br /> PHASI T <br /> APPLI ON ACCEPTED BY! DATE 3,.x6-7' <br /> _ _ <br /> ADDITIONAL COMMENTS: t <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> EH 1426 Rev_ 12-77 1- 17 2M <br />