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_a <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: <br /> 414111�01 E. Hazelton Ave, , Stockton, CA 95205 Permit No. ' <br /> Telephone. (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Expires 1 Year From Date Issued <br /> f <br /> Complete. In .Triplicate <br /> Application is hereby made to the San Joaquin focal 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 15672 E. Comstock Rd Linden CITY/TOWN�Li Linden <br /> Owner's Name Earl Westra Phone <br /> Address same City <br /> Contractor' s Name Clark Well & Equipment Li cense# 76602_ Phone 62,-559-2 <br /> IS CERTIFICATE OF WORKMAN'S ,COMP£NSATIO'! INSURAINCE ON FILE WITH SJLHD? YES .NO <br /> TYPE OF WORK (Check) : NEW WELLCM DEEPEN 0 RECONDITION ❑ DESTRUCTION❑ <br /> WELLItHLORINATION ❑ WELL ABANDONMENT 0 OTHER❑ <br /> PUMPINSTALLATION ❑ PUMP REPAIR 0 PUMP REPLACEMENT ❑ �- <br /> DISTANCE TO NEAREST: SEPTIC TANK/6�) 'SEWER LIN�FS PIT PRIVY <br /> SEWAGE DISPOSALvFI,ELD CESSPOOL/SEEPAGE PIT. OTHER <br /> PROP RTY-E:iNE=""PFIVATE DOMESTIC WELL — PUBLIC DOMESTIC WELL' <br /> t <br /> INTENDED USE TYPE OF WELL £ CONSTRUCTION SPECIFICATIONS i <br /> Industrial Cable Tool Dia. of Well Excavation 6,, . 1 d,, to 5o <br /> X Domestic/private D,rri11-ed R ;�Dia. of Well Casing 6 , <br /> Domestic/public ✓'• ' ' -'Driven 'Gauge of Casing #12 i e <br /> IrrigationGravel Pack Depth-of Grout Seal 50 ft <br /> Cathodic Protection X Rotary Type of Grout cement i } <br /> Disposal Other Other' Information <br /> Geophysical Surface Seal Instal ed by: <br /> + . <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump - . : w , . ,, . H. . <br /> PUMP REPLACEMENT: [] State Work DoneAf <br /> ! <br /> PUMP REPAIR: ❑State Work Done ---.M------ <br /> DESTRUCTION OF WELL: Well '!Diameter Approximate Depth-, - <br /> Describe Materia an 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, and Rules and, Regulations of the San Joaquin Local <br /> Health District. Home owner or licensed agent' s signature certifies the fallowing: <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 subjecf: to Workman's Compensation <br /> laws of California." <br /> I WILL CAL , OR' A GROUT.-I TION P IOR TO GROUTING AND A FtNALiINSPECTION. <br /> SIGNED TITLE: " DATE: <br /> DR W PLOT PLN ON REVS SE SIDE <br /> FOR DEPARTMENT USE: ONLY , <br /> PHAS-E <br /> PPL�ICATION ACCEPTED BY DATE -- <br /> ADDITIONAL COMMENTS: <br /> �- .P.RASE- 1.1-GROUT--INSPECT.. ON ----PHASE III FINAL INSPECTION.. <br />^zINSPECTION BY DAT INSPECTION BY DATE <br /> 1,,EH 1426' Rev. 12-77 1/78 2M.,,o, <br />