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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 iPermit No. <br /> Telephone: (209) 466-6781 <br /> a� APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued S <br /> This Permit Expires 1 Year From Date Issued <br /> Complete In Triplicate 0 bf-o.3o--q1 <br /> Application is hereby made to the San Joaquin Local Heal.th .District,for a permit to construct <br /> and/or install the work herein described. This application is made incompliance -with San <br /> .'eaquin County Ordinance No. 1862 and the Rules and- Regulations of the San Joaquin Local Health <br /> 2 �N <br /> EXACT STREET ADDRESS Rt 1 Box 48N H g way _2(-8 hop Area) CITY/TOWN Tselton <br /> Owner' s Name Bouldin Farming Co. , Inc. Phone 916-777-6091 <br /> Address Rt 1 Box 4$N Highway 12 City Iselton <br /> Contractor's Name Clark Well & Equip. ,Co. , Inc License# 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❑. N <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ -7'(1 <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT [� <br /> DISTANCE TO NEAREST: SEPTIC TANK +100 SEWER LINES +100 PIT PRIVY +150 { <br /> SEWAGE DISPOSAL, FIELD+100 CESSPOOL/SEEPAGE,PIT+100 OTHER <br /> _ <br /> PROPERTY -LINEIO..JPRIVATE DOMESTIC WELL +100 UBLIC DOMESTIC WEL r <br /> INTENDED USE ---TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool -Dia. of Well Excavation 10 <br /> Domestic/private Drilled Dia. of Well Casing <br /> x Domestic/public Driven Gauge of Casing Class 1 6n <br /> Irrigation Gravel Pack Depth of Grout SeaX Bentonite Quik=Gel ;i. <br /> Cathodic Protection x Rotary Type of Grout to impervius ..Cla <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: - <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump -- <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth 7 <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' <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 oftalifrn . <br /> I WILL CA "-OR G T PECT ON PRIOR TO GROUTING AND A FI L INSPECTION. <br /> SIGNED TITLE: _ -• .: - DATE <br /> DRAW PLT L N ON REVERSE SIDE <br /> F DEPARTMENT USE ONLY <br /> PHASE I �.•.,�:-- .� �..,.-_ <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONALCOMMENTS:.._ <br /> _ PHASE Ii GROUT INSPECTION -PHASE III FINAL INSPECTION <br /> INSPECTiQN BY DATE INSPECTION BY_��• DATE 7 <br /> F <br />'Cu i An-C n..: 9'n -7-7 " 5 'j : t 17A ')M <br />