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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.77 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issuedi,�:-1--�� <br /> This Permit Ex fires 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. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District, J�`13t/ U+4N71� ST iOg—/2o^2,(. <br /> EXACT STREET ADDRESS Well #54. Pacific Ave & Longviny Ac CITY/TOWN Stockton <br /> Owner' s Name California Water Services Company Phone 464-8311 <br /> Address 347 N . Sutter St. City Gt„ekton <br /> Contractor's Name Hennings Bros. Drilling Co Inc License# 290811 Phone 545-1165 <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES $ NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION® 12" Well <br /> WELL CHLORINATION ❑ WELL ABANDONMENT p OTHER❑ <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 W <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 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven - Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: M State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter .2 '' Approximate Depth 0 + <br /> Describe Materia andProce Procedure a ew <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 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 employ any person in such manner as to become subject to Workman's Compensation <br /> laws of California." <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED lignnings Bros, Drilling Co Inc b TITLE: �� e,. DATE: 11 -_10-78 <br /> (URAU L T PL ON REVERS SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �,aoP � , DATE '7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I FI AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ATE Z 0 <br /> l iv r J . /? aall g' ��// <br /> EH 1 6 R v. 1_ 77 7!�___ _ 1/78 2M_ _ <br />