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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. -J3a y <br /> Telephone: (209) 466-6781 . <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date issued -_;i 71' <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 thework hereinidescribed. This application is made in compliance with San <br /> Joaquin County Ordinance No 18U and the Rules and Regulations of the San Joaquin Lodal .Health <br /> District. <br /> EXACT STREET ADDRESS Tahama Village, 10780 North Highway 99 CITY/TOWN Stockton " <br /> Owner's Name Mike Carney Phone <br /> Address 74 New Montgomery St, - Suite 102 City San Francisco <br /> Contractor' s Name Clark Wellj.�* Equip. Co. , Inc. License#76602 Phone- 2-5597 <br /> E <br /> IS CERTIFICATE OF WORKMAN'S CO1,1PENSATIO`f INSURANCE ON FILE WITH SJLHD? YES X NO <br /> TYPE OF WORK (Check) : NEW WELL CA DEEPEN ❑ RECONDITION (] DESTRUCTION❑ p <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 0 OTHER❑ <br /> PUMP INSTALLATION..0 � PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE .TO NEAREST: SEPTIC TANK ' f` -SEWER- LINES w -- PIT PRI-VY- - <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 /> X Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal 501 <br /> Cathodic Protection i-r—Rotary Type of Grout Cement <br /> Disposal i Other Other Information <br /> Geophysical Surface Seal Installed by: OtFiers <br /> PUMP INSTALLATION: Contractor <br /> Type, of Pump H.P. <br /> PUMP REPLACEMENT: ].State Work Done <br /> PUMP REPAIR: O State Work Done -- . <br /> DESTRUCTION OF WELL: Well Diameter --' Approximate Depth <br /> Describe Mate r7a and Proce ure 2W <br /> 1 ' <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 , and Rules and Regulations of the San Joaquin Localti <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 employ any person in- such manner as to become subject to-Workman's Compensation <br /> laws of California." <br /> I WILL C FOR INSP CTION PRIOR TO GROUTING AND A- FINAL' INSPECTION. <br /> SIGNED i TITLE: Contractor DATE: 28 August 78 <br /> .I DRAW PLT PINON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> i <br /> APPLICATION ACCEPTED BY DATE 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE JI GROUT INSPECTION PHASE II FINAL INSPECTION J <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> Fu 1A9A Doti 17_77 1/78 . .2M <br />