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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br />_Fr . _ FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 2$;r­ _M <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION .OR PUMP .PERMIT Date Issued Sr J3--?� <br /> This Permit Ex fres-l 'Year From Date Issued . <br /> Complete In 'Triplicate <br /> 4pplicati6n is hereby made to the San Joaquin. Local . Health District for a permit to construct <br /> and/or install the work hereinadescribed: This application is made 'in compliance with San <br />'oaQuin County Ordinance No. 1862 and the Rules and- Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS. ,1O81, Bu I cham I,ane,U. O.P.Cam us CITY/TOWN Stockton_ <br /> awner's Name University of the Pacific Phone 946-2507 <br /> Address 3601 Pacifi-cAve City Stockton.. <br /> Contractor's Name Clark Well &' Equipment Co. , TNCCLicense# 76602 Phone 462-5597 <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑`.. --RECONDITION DESTRUCTION( <br /> .WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER 0 � <br /> PUMP INSTALLATION 0 PUMP REPAIR❑ PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK+100 SEWER LINES 1 0) ' PIT PRIVY+IOQ <br /> SEWAGE DISPOSAL FIELD +1 00 CESSPQOL/S+E g E PIT+ Q _ OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL + PUBLIC DOMESTIC WELL L 00 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial X Cable Tool Dia. of Well Excavation ) *e <br /> Domestic/private Drilled Dia: of Well Casing lo 4-, <br /> X Domestic/public Driven - Gauge of Casing . 250 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection I Rotary Type of Grout <br /> Disposal r Other Other Information <br /> Geophysical I Surface Seal Installed b : <br /> PUMP INSTALLATION: Contractor <br /> Type ofIPump H.P. <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: ❑State Work Done <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 , and Rules and Regulations of the San Joaquin Local I <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 e3p2,9y any person in such manner as to become subject to Workman's Compensation <br /> lawy falif r ia." <br /> I WILL A R A G OUT NS ION PRIOR TO GROUTING A FIN PELT. <br /> SIGNED TITLE: DATE: Jr <br /> (D%W PLOT PLAN ON REV RS ISTE) <br /> a1 FO DEPART% NT USE ONLY <br /> PHASE I l <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS : , <br /> PHASE II -GROUT INSPECTION PHASE III FINAL INS ECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> ru 1A09 D- 17_77 ° 1 /78 2M <br />